Applying Kotter’s Model of Change:

Case Study “ABC” Seniors Care Home

“ABC Senior Care Home” has 50 employees and according to WorkSafeBC, 25% of the
organization’s workplace injuries in 2014 and 2015 were due to acts of violence or aggression
from residents. In the long-term care sector, acts of violence or aggression account for 11% of
all injuries reported to WorkSafeBC. ABC Senior Care Home is above the provincial average for
injuries related to these types of incidents.

A coloured dot system to identify residents who are potentially aggressive or violent exists at
ABC, however an audit revealed that staff were updating the dots only after a staff member
had been injured as a result of aggression or violence, not when they had observed change in
behaviour. 65% of the nursing staff had undergone point-of-care risk assessments training in
2012, however this left some shifts without any staff trained to assess residents at point-of-
care. This created a larger volume of point-of-care assessments to be done on shifts with
trained staff.

The last violence prevention training for all staff was in 2012 and since then a large number of
trained staff retired and replaced with staff who have not had recent violence prevention
training. Hires since 2012 were provided ABC’s policies and procedures on workplace violence
in written form at point of hire.

Policies and procedures for point-of-care risk assessments and updating the coloured dot
system exist but are often not used and mostly followed only when an incident is reported.

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Part 1) Applying the Safety Culture Framework
Many of the dimensions in the safety culture framework need to be addressed in this case
study. Where does this organization fall on the spectrum for the following dimensions?
• Commitment to prevention and continuous improvement
• Priority Given to Staff Safety
• Staff education and training about safety issues

Part 2) Applying Kotter’s Model of Change

Using Kotter’s model of change, apply the 8 steps to this case study using one of the
identified dimensions of the safety culture framework.

1. Create a sense of urgency

• What threats exist if changes are not made? What are the benefits to making
changes?
• Identify the top 3 reasons to make a change.

2. Form a powerful coalition

• Who would you choose to be part of the coalition to champion the change?

3. Create a Vision for Change

• What are the values central to the vision?
• What is the vision of success? Be specific!

4. Communicate the Vision

• How would you communicate or demonstrate the vision?
• Where would you embed the vision in the organization?

5. Remove Obstacles
• What barriers exist to implementing the change?
• What would you do to remove these barriers?

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6. Create short-term wins
• What are the simple and inexpensive things this organization can do to make change?

7. Build on the change

• If progress was being made as a result of the changes, how might you build on this
momentum?
• Who might be new agents of change to add to the coalition?

8. Anchor the change in culture

• What success stories might you share and how would you share these stories?
• How would you celebrate the success and recognize agents of change?
• How would you embed the change in succession planning, hiring and training?

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 Applying Kotter’s Model of Change:

Identify a safety issue or opportunity that requires change in your own organization and apply
Kotter’s 8-step process:

1. Create a sense of urgency

• What threats exist if changes are not made? What are the benefits to making
changes?
• Identify the top 3 reasons to make a change.

2. Form a powerful coalition

• Who would you choose to be part of the coalition to champion the change?

3. Create a Vision for Change

• What are the values central to the vision?
• What is the vision of success? Be specific!

4. Communicate the Vision

• How would you communicate or demonstrate the vision?
• Where would you embed the vision in the organization?

5. Remove Obstacles
• What barriers exist to implementing the change?
• What would you do to remove these barriers?

6. Create short-term wins

• What are the simple and inexpensive things this organization can do to make change?

7. Build on the change

• If progress was being made as a result of the changes, how might you build on this
momentum?
• Who might be new agents of change to add to the coalition?

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8. Anchor the change in culture
• What success stories might you share and how would you share these stories?
• How would you celebrate the success and recognize agents of change?
• How would you embed the change in succession planning, hiring and training?