Research Paper

International Journal of
Pharmacy Practice
International Journal of Pharmacy Practice 2015, 23, pp. 439–446

Change management in pharmacy: a simulation game and

pharmacy leaders’ rating of 35 barriers to change
Aurélie Guérina, Denis Lebela, Kevin Hallb and Jean-François Bussièresc
a
Pharmacy Department, CHU Sainte-Justine, Montreal, QC, bFaculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, AB,
Canada, and cFaculty of pharmacy, Université de Montréal, Montreal, QC

Keywords
barriers; change management; pharmacy;
simulation game
Correspondence
Mr Jean-François Bussières, Pharmacy
Department, Centre Hospitalier Universitaire
Sainte-Justine (CHUSJ), 3175, Chemin de la
Côte-Sainte-Catherine, Montréal, QC H3T
1C5, Canada.
E-mail: jf.bussieres@ssss.gouv.qc.ca
Received November 21, 2013
Accepted May 25, 2015
doi: 10.1111/ijpp.12199
Ethics committee approval: No Ethics
committee approval was needed for this study.
Abstract
Objectives The primary objective was to rank barriers to change in pharmacy prac-
tice. Our secondary objective was to create a simulation game to stimulate reflection
and discussion on the topic of change management.
Methods The game was created by the authors and used during a symposium
attended by 43 hospital pharmacy leaders from all regions of Canada (Millcroft Con-
ference, Alton, Ontario, June 2013). The main theme of the conference was ‘manag-
ing change’.
Key findings The simulation game, the rating of 35 barriers to change and the dis-
cussion that followed provided an opportunity for hospital pharmacy leaders to
reflect on potential barriers to change, and how change might be facilitated through
the use of an organized approach to change, such as that described in Kotter’s eight-
step model.
Conclusions This simulation game, and the associated rating of barriers to change,
provided an opportunity for a group of hospital pharmacy leaders in Canada to
reflect on the challenges associated with managing change in the healthcare setting.
This simulation game can be modified and used by pharmacy practitioners in other
countries to help identify and rank barriers to change in their particular pharmacy
practice setting.

Introduction context of improving the quality of health care in the United

Pharmacy leaders and managers are expected to establish and
maintain high pharmacy practice standards, ensure compli-
ance with laws and regulations and effectively and efficiently
manage resources. At the same time, they are expected to
respond to the challenges they face in a healthcare environ-
ment that is changing at a rapid pace. Strategies that worked
in the past may no longer be effective in today’s environ-
ment.[1] Pharmacy leaders must be prepared to not only adapt
to new circumstances, but also to lead change.[2] Change man-
agement is a competency that effective pharmacy leaders
learn to master.
There is an abundant literature published about change
management with more than 4000 published titles in the
getAbstract database alone.[3] In Pubmed, change manage-
ment is covered under the MeSH term ‘Organizational inno-
vation’ and includes more than 23 000 titles.[4] Ferlie et al.
have proposed a multilevel framework for change in the
Kingdom and United States.[5] The authors noted that atten-
tion must be given ‘to issues of leadership, culture, team
development, and information technology at all levels’.[5]
Others have proposed different approaches to transforma-
tional change in healthcare systems.[6–13]
Although there are numerous publications that describe
the evolution of pharmacy practice,[14–18] there are only a
limited number of publications that deal with specific change
management initiatives in pharmacy. In a qualitative study,
Gastelurrutia et al. conducted 33 semi-structured interviews
with community pharmacists and identified 12 factors that
facilitated practice change in community pharmacies in
Spain.[19] Feletto et al. tested a pharmacy ‘change readiness
wheel’ when implementing a pharmacy asthma management
service in Australia and concluded that ‘change is not as
straightforward as it may appear and is a multi-step process
over time’.[20] Doucette et al. surveyed 400 licensed U.S. phar-
macists to assess the extent of pharmacy practice change that

© 2015 Royal Pharmaceutical Society International Journal of Pharmacy Practice 2015, 23, pp. 439--446
440
had occurred in recent years.[21] The authors concluded that
‘many pharmacies reported that some aspects of their prac-
tice have changed, such as collecting patient information and
documenting care’.[21] However, few participants reported
that significant changes, such as asking patients to pay for
pharmacy services, had occurred. Roberts et al. have also
published a number of papers on practice change and its
understanding.[22–24]
Tsuyuki and Schindel proposed that the Kotter model of
change management could be used as a tool for accelerating
practice change in the pharmacy setting.[25] The steps pro-
posed by Kotter for maximizing the potential for achieving
meaningful change are: (1) instill a sense of urgency; (2) build
a guiding coalition; (3) create a vision and supporting strat-
egies; (4) communicate the vision; (5) empower employees to
take action; (6) generate short-term gains; (7) consolidate
improvements and produce more change; and (8) anchor
new approaches in the culture.[26]
Our primary objective was to identify and rank barriers to
change in pharmacy practice. Our secondary objective was to
create a simulation game to stimulate reflection and discus-
sion on the topic of change management.
Methods
Patients and settings
The participants were all pharmacy leaders (n = 43) attend-
ing the invitational Millcroft Pharmacy Leadership Confer-
ence (Alton, Ontario, Canada. 7 June 2013).
Creation of the simulation game
Following a brief literature review of Kotter’s eight-step
process for leading change, the authors and several colleagues
conducted a brainstorming session and identified a list of 35
barriers to change that could apply to pharmacy practice.[26]
Kotter’s model was chosen because it is simple, well known
and has been used in the healthcare sector. A number of bar-
riers were identified for most of the steps in the Kotter model.
A barrier to change was considered as anything that could
hinder or slow the implementation of a pharmacy practice
change.
The simulation game used a negotiation-based format that
was designed to be played by up to eight groups, with four to
six individuals in each group. Each group represented a
virtual pharmacy department. The authors identified one
member of each group to act as the leader of the virtual
department. That person was responsible for ensuring that
the game was completed within the allotted time (e.g.
60 min). Each group was provided with 41 construction
blocks in a mix of four colours. The four colors of the blocks
were used to represent four pharmacy practice domains: drug
© 2015 Royal Pharmaceutical Society
Change management in pharmacy
distribution, clinical services, research and management. The
game board had only 28 spots for placement of the blocks, so
participants had to decide how many blocks of each phar-
macy domain (clinical, drug distribution, research and man-
agement) that they wanted to include in their pharmacy
model. Each table group had the opportunity to build their
ideal pharmacy department but also faced the challenge of
reaching agreement among the group members on what that
ideal pharmacy should look like with respect to the clinical,
drug distribution, research and management services that
would be part of their ideal pharmacy. Although other
domains, such as education, could have been included, the
authors decided upon these four major domains to facilitate
the timely completion of the game.
Each person, including the ‘director of pharmacy’, was ran-
domly given a game card with three sections. Game cards
were developed to promote participation by all group
members and to create situations where opposition to change
would emerge. Each person also received a role, such as direc-
tor of pharmacy, drug distribution coordinator, research
coordinator, automation and information technology phar-
macist, pharmacology and therapeutics’ committee pharma-
cist, intensive care unit pharmacist, internal medicine
pharmacist, and pharmacy technician. The game card also
described their personality characteristics, values, biases and
their and their priorities/specific objectives related to phar-
macy services (drug distribution, clinical services, etc.). Each
player was instructed to pursue their character’s priorities as
they played the game and not share the content of their game
card. Table 1 provides a description of the content of the eight
game cards.
The simulation game and the tools used in the game were
pre-tested with a group of eight pharmacy residents for
clarity and understanding. As a result of the testing, minor
changes were made regarding the game instructions and time
allocation.
Playing the simulation game
The game was conducted in English, with supplemental
instructions provided in French for those who requested it.
Participants were notified that participation in the simulation
game was voluntary and that the authors planned to publish
the results of the simulation game. No ethics approval was
sought from an institutional human ethics research commit-
tee, considering the nature of the simulation.
Conference attendees had previously been placed at tables
in the conference room as part of the overall planning for the
conference. The seating arrangements were designed to create
groups at each table that represented a balance of individuals
from each region of the country. The same seating arrange-
ments were maintained for the simulation game. The game
took a total of 60 min, including the time required to provide
International Journal of Pharmacy Practice 2015, 23, pp. 439--446
 Table 1 Description of the content of the eight game cards
Roles
Pharmacy director
ICU pharmacist
Research coordinator
International Journal of Pharmacy Practice 2015, 23, pp. 439--446
Distribution coordinator
Internal medicine pharmacist
P & T pharmacist
Pharmacy technician
Automation and IT pharmacist
© 2015 Royal Pharmaceutical Society
Personality characters
Not a funny fellow at all; no joke
please and make sure the group
focus on the task; this is not party
time!
Always has something to say or add
to a discussion; likes to interrupt
other people.
A little bit frustrated fellow; can be
aggressive in making his point,
particularly if nobody seems to be
listening to him.
A funny fellow having a good time at
work and in his life; will use
humour to make his point; likes to
laugh and make others laugh.
A question person; always asking
questions, but rarely has answers
to those questions
Has personal healthcare and
emotional problems; job should
not create more stress in our life
Very nice fellow, with good attitude;
very helpful in a group dynamic;
helps decisions to be made
efficiently
Very techno wise fellow with always a
technical solution to any kind of
problem
Values
Dislikes chaos and makes sure one
person talks at a time
Equality . . . likes it when everything is
equal
Rigor, rigor, rigor !
Job should be fun because life is short
! (e.g. blue blocks) in the model as
Takes into account all voices and likes
it when other people have
questions too !
Can we keep things simple please
A leader that make things happen;
did not go into pharmacy because
of a healthcare problem but makes
a difference in a group dynamic;
might return to school
Not very clear ins his explanations
because he uses a lot of jargon,
technical tips and never ending
answers
Bias
Wants to increase management
staffing (yellow blocks) as the
current challenges are enormous
and without more resources, he
might leave the hospital
Wants to increase clinical staffing (red
blocks); what would pharmacy be
without clinical pharmacists!
Wants to increase research and
clinical staffing (green and red
blocks); pharmacy management is
the one thing everyone can do;
does not like the director at all.
Wants to increase distribution staffing
distribution is the basis of
pharmacy practice.
Wants to increase clinical staffing (red
blocks); all spheres of pharmacy
practice are important but clinical is
our future
Likes the model as it is and believes
that the system swill decide for us
anyway, no matter what we want
Will find the best compromise for the
game, taking into account external
and internal pressure
Wants to add more management
staffing to get some additional
time for IT implementation,
exploration, development, etc.
Specific objectives related to the
game
To add two yellow blocks to the
model, no matter what’s taken out
Aurélie Guérin et al.
; you must succeed
To add two red (clinical) blocks to the
model by reducing the blue (drug
distribution) blocks; may make
deals with others to overwhelm the
blue (drug distribution) supporters.
To add 2 green to the model and
wants to reduce yellow to barely its
minimum (e.g. 1 or 2)
To add 2 more blue and may trade
with any other fellow; while funny,
he must win.
To add 1 or 2 red block (s) to the
model and not reduce anyone; let
us see what the institution will say ;
let us find a way to reduce any
pharmacy staffing reductions;
pharmacy should stand up and
argue for its indispensability
To make change at all
Let’s win the game (e.g. complete the
model and follow the game leader
rule because not following the rule
means losing the game), lead the
group, and make model more
coherent than the initial version
To add at least 2 yellow blocks; will
pretend that 1 yellow block can
replace 2 blue or 2 red because
machines can replace people, do
not get sick and make work more
efficient
441
442 Change management in pharmacy

Table 2 Simulation game instructions

You are at a departmental retreat and are seated with a group of your colleagues who have been assigned the task of making important decisions
about the future of your pharmacy department. You all work for a 500-bed teaching hospital. The pharmacy department offers a fairly
comprehensive range of services. The department operates a unit dose drug distribution system, with a reasonably comprehensive, centralized
intravenous admixture program. Some automation technologies are in use and the pharmacy has a pharmacy information system that includes a
number of decision-support functionalities, such as drug interaction and drug dosage checking. Your department is perhaps mid-way towards full
implementation of the medication management standards of Accreditation Canada. The department provides experiential training to both
undergraduate and post-graduate pharmacy students (residents) and your department supports and participates in clinical research. Your pharmacy
department is currently described by the mega block model that is on your table. Theses blocks illustrate the current pharmacy practice model. By
model we mean the importance of each domain of pharmacy (i.e. drug distribution, pharmaceutical care, research and management).
Each colour represents a domain of your pharmacy model: blue (drug distribution), red (pharmaceutical care), green (research) and yellow
(management). Teaching is embedded in each colour since experiential training is provided to students who work in each of the domains (drug
distribution, patient care, research and management). Your current model includes 28 blocks. Each pharmacy member at your table has a game
card that describes their role, a personality characteristic that they have, their personal values, a bias that they have, and a specific objective that you
have for this planning game with your colleagues. Do not share this information with the other members at your table.
At the signal of the game leader, the table members will begin to discuss how they could improve the current pharmacy practice model by altering the
relative weight of each of the four pharmacy domains (drug distribution services, clinical services, research and management). The game leader may
interrupt the game at any time to inform each pharmacy department of government or CEO decisions that may affect your decisions. The game will
last 20 min.

verbal and written instructions at the start of the session and
to wrap-up the session at the conclusion of the game
(Table 2). A photo of the ideal pharmacy model that was
created by each of the eight teams was taken for viewing by all
conference participants and subsequent discussion later
during the conference.
Rating the importance of barriers to change
After the teams had completed the simulation game, each
participant was given a questionnaire to fill out, along with
the list of 35 barriers to change that had been identified. A
short demographic section was included in the question-
naire. Each participant was asked to rate how important each
barrier was, considering both what they had experienced
during the game and in their own practice experience. The
following rating scale was used: ‘very important = 1, impor-
tant = 2, somewhat important = 3, not at all important = 4’.
The rating exercise was conducted in an effort to have the par-
ticipants give some thought to the various barriers that often
have to be overcome when change is being planned and
implemented. Each participant was also invited to provide
written comments about the simulation game at the end of
the questionnaire.
Follow-up with participants
The following day, the eight different models of an ideal phar-
macy, based on the distribution of blocks representing clini-
cal, drug distribution, research and management services,
were reviewed by the conference participants. The groups had
encountered many challenges as they tried to create the ideal
pharmacy model. The discussion that followed focused on
some of the major barriers that the groups had encountered.
The comments received were anonymously recorded by the
authors. The comments were reviewed by the authors, but no
in-depth analysis was conducted.
Analysis
Using each individual’s rating for the 35 barriers, an average
rating for all participants was calculated for each of the
35 barriers to change. No other statistical analysis was
conducted.
Results
Demographics of the participants
Forty-five per cent of the participants were in the age range of
41–50 years of age; 30% were in the range of 51–60 years of
age; 17.5% were in the range 30–40 years of age; 5% were
under 30 years of age and 2.5% were more than 61 years of
age. Table 3 shows the distribution of roles given to the par-
ticipants. The simulation game was conducted on 7 June 2013
at the invitational Millcroft Pharmacy Leadership Confer-
ence held in Alton, Ontario, Canada. All of the pharmacy
leaders in attendance at the conference (n = 43) participated
in the simulation game.
Table 4 shows, in decreasing importance, the average rating
of the importance of the 35 barriers to change, as rated the by
pharmacy leaders. Lack of leadership, lack of a common
vision and lack of a clear game plan or strategic vision
were rated as the most important barriers to change by the
participants.

© 2015 Royal Pharmaceutical Society International Journal of Pharmacy Practice 2015, 23, pp. 439--446
Aurélie Guérin et al. 443

Table 3 Distribution of roles randomly given to pharmacy leaders for the game simulation and average rating for the 35 barriers per team

Groups

A B C D E F G H
(n = 5) (n = 6) (n = 6) (n = 5) (n = 6) (n = 5) (n = 4) (n = 6)
Roles

Pharmacy director X X X X X X X X
Intensive care unit pharmacist X X X X X
Research coordinator X X X X X
Distribution coordinator X X X X X
Internal medicine pharmacist X X X X X X
Pharmacology and X X X X X X X
therapeutics’ committee
pharmacist
Pharmacy technician X X X X
Automation and information X X X
technology pharmacist

Table 4 Rating of barriers to change by pharmacy leaders post-simulation

Pharmacy
Kotter’s model[27] Barriers to change leaders rating

2 Lack of leadership 1.4

3 Lack of common vision 1.5
3 Lack of clear game plan or strategic vision 1.5
4 Lack of effective communication throughout the implementation 1.7
6 Lack of formal support from the management team to make change a real priority 1.8
3 Lack of strategic support within the hospital 1.9
5 Lack of culture conducive to change 2.0
6 Lack of feedback/support/encouragement from the management team 2.0
2 Lack of collaboration 2.0
1 Lack of a sense of urgency 2.0
4 Lack of understanding about what the individuals targeted by the change are to do 2.1
3 Lack of favorable impact on patient outcome 2.1
4 Lack of prior and adequate consultation with individuals targeted by the change 2.1
5 Lack of identification of the individuals likely to stand in the way of change 2.1
3 Lack of anticipation of the real impacts of the change 2.1
5 Lack of identification of the individuals likely to stand in the way of change 2.1
5 Lack of financial resources 2.2
5 Lack of adequate training of the targeted individuals specifically focused on the change to be implemented 2.2
3 Lack of identification of potential barriers to change 2.3
5 Lack of general training on managing change 2.3
6 Lack of easy-to-follow outcome indicators of change 2.3
2 Lack of consideration of the resistance expressed by some individuals targeted by the change 2.3
6 Lack of readjustments/corrections made to the processes being implemented 2.3
2 Lack of conducive work environment 2.4
4 Lack of an optimal description of the tasks of the individuals targeted by the change 2.4
3 Lack of confidence 2.4
3 Lack of scientific basis or conclusive data to justify the change 2.4
5 Lack of human resources 2.4
2 Lack of consideration of the worries of the individuals targeted by the change 2.4
2 Lack of legitimacy of the identified individuals involved 2.5
2 Lack of formally identified individuals involved 2.5
5 Lack of material resources 2.6
5 Lack of scientific/technical expertise on the team 2.6
2 Lack of adequate autonomy given to those targeted by the change 2.6
7 Lack of consideration of previous change failures 2.7

International Journal of Pharmacy Practice 2015, 23, pp. 439--446 © 2015 Royal Pharmaceutical Society
444
Figure 1 Ten top barriers mapped into the Kotter model.
Figure 1 illustrates the most important barriers to change,
classified according to the Kotter model by the participants
through the simulation game.[26]
Most comments were provided verbally by the partici-
pants. Although they appreciated the simulation game, they
mentioned they were surprised by the number of potential
barriers and expressed their difficulty in ranking with accu-
racy a long list of items. A few mentioned they are usually
aware of the personality and characteristics of stakeholders in
a change process while the game did not allow the partici-
pants to learn anything about the roles that others within the
group would be playing. Some participants also felt that they
needed to know more information about the ‘simulation hos-
pital’ in order to make relevant decisions.
Discussion
Among the top-10 barriers identified by the participants, at
least one barrier was deemed to be relevant for six of the eight
steps of the process proposed by Kotter.[26] Using a simulation
game has strengths and limitations. In terms of strengths, the
simulation game developed was simple, fun and could be
conducted with little investment and with different audi-
ences. It allowed interactions and discussions followed by
reflections about barriers to change.
In terms of limitations, participants were given only a short
period of time to execute the simulation game and rank the
list of 35 barriers to change. A longer time period could have
© 2015 Royal Pharmaceutical Society
Change management in pharmacy
been allowed. Limited instructions were given about the
nature of the hypothetical hospital (e.g. the hospital’s pro-
grammes of care or workload volumes), within which the
participants were asked to design their ideal pharmacy
department. Some participants felt that they needed that
information in order to make decisions about the emphasis
that should be placed on each of the four domains (drug dis-
tribution, clinical, research and management). A more com-
prehensive description of that hospital could be developed
and provided. Participants were asked to indicate the impor-
tance of all barriers, whereas some respondents indicated that
they did not have enough time to thoughtfully consider and
rate the importance of all 35 barriers to change. Although list
of barriers provided is not exhaustive, we believe that this ini-
tiative did achieve its goal of facilitating a discussion of
change management by the pharmacy leaders in Canada who
participated in the simulation game and the rating of barriers
to change.
Any barrier may block a proposed change, regardless of its
relative position in a ranking. Although the ranking proposed
by participants may put an emphasis on some barriers, we
believe that pharmacy leaders should consider all possible
barriers as they undertake change initiatives. Particular atten-
tion should be given to the common barrier of ‘past experi-
ence’, where a change initiative failed (‘been there, done that,
and know it won’t work’). The simulation game does not
allow us to understand why pharmacy leaders have ranked
that important barrier at the very last position of their
International Journal of Pharmacy Practice 2015, 23, pp. 439--446
Aurélie Guérin et al. 445

ranking, but we do hope people learn from their success and
failure and do consider that in change management. To our
knowledge, there is not similar ranking of barriers to change
by pharmacy leaders that has been published.
In 2000, Balas et al. published a paper in which they exam-
ined the time it took for nine clinical interventions to be
adopted, following the landmark trial(s) that had demon-
strated their clinical effectiveness.[27] They reported that there
was an average 3.2% increase in the use of the intervention
per year. Put another way, the authors reported that on
average it would take 15.6 years to reach a rate of use of 50%
for a proven clinical intervention. A look at the more than 20
years of data that have been collected by the Hospital Phar-
macy in Canada survey suggests that the adoption of innova-
tions in pharmacy practice, such as the adoption of unit dose
and IV admixture systems, has been similarly slow with
respect to their uptake.[17] Clearly, there are many reasons why
pharmacy managers and practitioners should be interested in
accelerating the process of change.
We could find only a few reports concerning the use of
simulation games to increase awareness of pharmacy man-
agement concepts.[28–31] Our simulation game provided an
opportunity for hospital pharmacy leaders to consider how
change in their organization might be managed more effec-
tively. Although we did not conduct a formal assessment of
the simulation game’s effectiveness, feedback provided by
participants as part of the conference evaluation form indi-
cated that the game achieved its intended purpose of facilitat-
ing the discussion and reflection on change management that
it was designed to achieve.
Conclusions
This simulation game and the associated rating of barriers to
change provided an opportunity for hospital pharmacy
leaders in Canada to reflect on the challenges associated with
managing change in the healthcare setting. The slow adoption
of innovations in the healthcare setting represents a lost
opportunity for everyone who relies on the healthcare system
to provide the best possible healthcare services. Strategies to
accelerate the rate of adoption of healthcare innovations need
to be pursued. Simulation games can serve as a starting point
for reflection and discussion related to the management of
change. Others could adapt and use a similar game to engage
managers and staff in the early stage of change initiatives. This
simulation game can be modified and used by pharmacy
practitioners in other countries to help identify and rank bar-
riers to change in their particular pharmacy practice setting.
Declarations
Conflict of interest
The Author(s) declare(s) that they have no conflicts of inter-
est to disclose.
Funding
This work received no specific grant from any funding agency
in the public, commercial or not-for-profit sectors.
Authors’ contributions
DL and JFB contributed to the original design and conception
of the study. AG, DL and JFB prepared the simulation game.
AG, DL, KH and JFB approved by consensus the list of criteria
to be used. JFB presented the simulation game to the partici-
pants. AG and JFB acquired the data. AG, DL, KH and JFB
analyzed and interpreted the data. AG and JFB wrote the first
draft. AG, DL, KH and JFB revised the draft critically for
important intellectual content.AG, DL, KH and JFB approved
the final version to be published. All Authors state that they
had complete access to the study data that support the
publication.

References &allCategories=true&allRatings organizational model. Health Care

1. Manasse HR Jr. Health-system pharm-
acy’s imperative for practice model
change. Am J Health Syst Pharm 2012;
69: 972–978.
2. Zellmer WA. The future of health-
system pharmacy: opportunities and
challenges in practice model change.
Ann Pharmacother 2012; 46: S41–S45.
3. getAbstract (1999–2015). Summary
search strategy: change management.
[online] http://www.getabstract.com
/en/search/?query=change
+management&allFormats=true
&allSources=true
=true&allPublicationYears=true
&languageIds=1 (accessed 24 Decem-
ber 2014).
4. PubMed (2015). Organizational Inno-
vation [Mesh]. [online] http://www
.ncbi.nlm.nih.gov/pubmed?term=%22
Organizational+Innovation%22%5
BMesh%5D (accessed 24 December
2014).
5. Ferlie EB et al. Improving the quality of
health care in the United Kingdom and
the United States: a framework for
change. Milbank Q 2001; 79: 281–315.
6. Lukas CV et al. Transformational
change in health care systems: an
Manage Rev 2007; 32: 309–320.
7. Harrison MI et al. Building capacity for
a transformation initiative: system
redesign at Denver Health. Health Care
Manage Rev 2009; 34: 42–53.
8. Harlos K et al. Mining the management
literature for insights into implement-
ing evidence-based change in health-
care. Healthc Policy 2012; 8: 33–48.
9. Al-Balushi S et al. Readiness factors for
lean implementation in healthcare set-
tings – a literature review. J Health
Organ Manag 2014; 28: 135–153.
10. Agency for healthcare research and
quality (2014). TeamSTEPPS 2.0.

International Journal of Pharmacy Practice 2015, 23, pp. 439--446 © 2015 Royal Pharmaceutical Society
446
Module 8 – Change management.
[online] http://www.ahrq.gov/
professionals/education/curriculum
-tools/teamstepps/instructor/
fundamentals/module8/
igchangemgmt.html (accessed 24
December 2014).
11. Prosci (2015). ADKAR® Model.
[online] http://www.prosci.com/
adkar-model/overview-3/ (accessed 24
December 2014).
12. Kritsonis A. Comparison of change
theories. Int J Manag Bus Adm
2005; 8: 1–6. [online] http://www
.nationalforum.com/Electronic%20
Journal%20Volumes/Kritsonis,%20
Alicia%20Comparison%20of
%20Change%20Theories%20IJMBA
%20V8%20N1%202005.pdf (accessed
24 December 2014.)
13. Brio Conseils (2012). Qu’est-ce qu’une
bonne démarche de gestion de
changement? [online] http://www
.brioconseils.com/blog/134/un-outil
-de-mesure-efficace-en-gestion-du
-changement%E2%80%A6-le-modele
-des-phases-de-preoccupations-de
-celine-bareil-de-hec-montreal/
(accessed 24 December 2014).
14. Pedersen CA et al. ASHP national
survey of pharmacy practice in hospital
settings: prescribing and transcribing-
2013. Am J Health Syst Pharm 2014; 71:
924–942.
15. Pedersen CA et al. ASHP national
survey of pharmacy practice in hospital
settings: monitoring and patient
education-2012. Am J Health Syst
Pharm 2013; 70: 787–803.
© 2015 Royal Pharmaceutical Society
16. Pedersen CA et al. ASHP national
survey of pharmacy practice in hospital
settings: dispensing and admini-
stration-2011. Am J Health Syst Pharm
2012; 69: 768–785.
17. Hospital Pharmacy in Canada Editorial
Board (2013). Hospital Pharmacy in
Canada Report 2011/2012. [online]
http://www.lillyhospitalsurvey.ca/
hpc2/content/rep_2012_tocF.asp
(accessed 24 December 2014).
18. European Society of Hospital Pharma-
cists (2010). EAHP’s 2010 survey of
hospital pharmacy practice in Europe.
Survey 2010. [online] http://www
.eahp.eu/publications/survey/eahps
-2010-survey-hospital-pharmacy
-practice-europe (accessed 24 Decem-
ber 2014).
19. Gastelurrutia MA et al. Facilitators for
practice change in Spanish community
pharmacy. Pharm World Sci 2009; 31:
32–39.
20. Feletto E et al. Practice change in com-
munity pharmacy: using change-
management principles when
implementing a pharmacy asthma
management service in NSW, Australia.
Int J Pharm Pract 2013; 21: 28–37.
21. Doucette WR et al. Organizational
factors influencing pharmacy practice
change. Res Social Adm Pharm 2012; 8:
274–284.
22. Roberts AS et al. Understanding prac-
tice change in community pharmacy: a
qualitative research instrument based
on organisational theory. Pharm World
Sci 2003; 25: 227–234.
International Journal of Pharmacy Practice 2015, 23, pp. 439--446
Change management in pharmacy
23. Roberts AS et al. Understanding prac-
tice change in community pharmacy: a
qualitative study in Australia. Res Social
Adm Pharm 2005; 1: 546–564.
24. Roberts AS et al. Practice change in
community pharmacy: quantification
of facilitators. Ann Pharmacother 2008;
42: 861–868.
25. Tsuyuki RT, Schindel TJ. Changing
pharmacy practice: the leadership chal-
lenge. Can Pharm J 2008; 141: 174–180.
26. Kotter J (2015). The 8-Step process for
leading change. [online] http://
www.kotterinternational.com/our
-principles/changesteps/changesteps.
(accessed 24 December 2014).
27. Balas EA, Boren SA. Managing clinical
knowledge for health care improve-
ment. Yearb Med Inform 2000; 65–70.
28. Bregman D et al. An internet-based
simulation system for training and
development of regional-healthcare-
centers managers. Stud Health Technol
Inform 2009; 150: 789–793.
29. Mann BD et al. The development of an
interactive game-based tool for learn-
ing surgical management algorithms
via computer. Am J Surg 2002; 183:
305–308.
30. Renet S et al. Prioritizing pharmaceuti-
cal activities: a simulation exercise. Can
J Hosp Pharm 2012; 65: 119–124.
31. Renet S et al. Prioritizing pharmaceuti-
cal activities: a simulation with phar-
macy residents. J Pharm Pract 2013; 26:
366–374.