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Dissertation Proposal: Doctor Of Business Administration

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Question:

Describe about the Nature of Successful Strategic Change Initiatives in Healthcare Organizations: A Multiple Case Study?

 

Answer:

Abstract

This particular study reflects the nature of successful strategic change initiatives in the health care organization with the help of multiple case studies. In every organization or industry especially in corporate sector, success factor related with the implementation of various nature of strategic change initiatives. In this particular study demonstrated the various natures of successful strategic change initiatives that are well discussed and documented in the management literature. However, researcher firmly focused on analyses or discusses the nature of strategic changes in the health care organization. The main purpose of this multiple case study was to identify the nature of strategic change initiatives that generate success for the health care organization and helps in positioning themselves in the competitive market. Researcher outlined the factors of strategic change initiatives that generate success via gathering the qualitative data from managers of health care organization in the region of Middle Atlantic in United State.

In order to get more data or information, researcher conducts in-depth analysis with the entire level managers as well as employees through personal interviews. Researcher employed the inductive qualitative analysis in order to identify the nature of successful strategic change initiatives. Researcher also compared the results of this analysis with the success factor of strategic change that described in the literature review part. After comparing the actual result with the secondary research, researcher drawn the generalization were added significantly in the literature management especially in the health care industry in the region of Middle Atlantic in United State.

Few specific success factors were identified regarding the implementation of strategic change initiatives such as values & culture, people and engagement, process of business, etc. However, the two identified factors that were unique in terms of future success in heath care organization in the region of Middle Atlantic in United State such as satisfaction of patients and quality service care. Apart from that, there was another success factors that identified in the health care organization named access to information.

Chapter 1: Introduction

Contextual factors specific to the healthcare sector, such as changing population demographics (Gordy and Trunky, 2014), updated health care protocols  (Gordy and Trunky, 2014), labor regulations (Free, 2013) and enhanced standards of care (Ash, Seago and Spetz, 2014) have triggered the need for ongoing  strategic changes and challenges within health care organizations across the USA (Greshengorn, Kocher & Factor, 2013).  It is noted that there are a number of studies related to strategic change management in organizations which are well documented in the management literature (Kuipers et al. 2013; Weitzel & Van Gorp, 2014). However, the fact is that all these studies were revolved around a particular aspect as, “how the particular healthcare organizations were engaged in multiple strategic change initiatives” (Arbab Kash et al. 2014; McAlearney et al. 2013; p.207). No such studies were found that tried to identify the critical factors that support the health care organizations to adopt strategic change initiatives. As a consequence, annual spending on health care and resource allocation in this area far exceed global norms without clear clinical benefit in the patient healthcare delivery (Perla, 2013; Naylor 2012). 

As mentioned by Radnor, Holweg & Waring (2012), large-scale change efforts necessitate a careful planning as well as management initiatives.  It is the responsibility of health care administrators to successfully manage these ongoing change initiatives and deliver high-quality, efficient patient healthcare in a financially sustainable manner, which today remains more of a challenge in the healthcare environment than ever before (Nembhard & Edmondson, 2011). As the demand and pressure on the health care sector is rising constantly in a diverse environment, the role of health care managers has gained much importance in recent times (Birken Lee & Weiner, 2012). Changes are brought in health care organizations to improve the quality of health care facilitation addressing the misuse of services, use of services, and return on these services (Kuipers et al. 2013). At the same time as informed by Free (2013), reducing medical errors and improving quality health care is another area met through organizational change. The use and misuse of services can easily be found in the health care system, it is very difficult for health care managers to control these factors due to difference in health care science development and evidence based practice (McAlearney et al. 2013).  Specifically, there is a need for a more comprehensive research to evaluate health care administrators’ abilities and capacity to involve successful change initiatives within health systems (Swayne, Duncan & Ginter, 2012; Walshe & Smith, 2011).

Health care organizations have faced many strategic changes in last few years especially in the last five to seven year tenure. According to Leonard (2014), the changing aspect in the health care policies and the change population demographics has forced the industry to develop new strategies. Chapter 1 of this Proposal  provides the overview of the study with the explanation of nature of successful strategic change initiatives in health care system especially for the Middle Atlantic in United State. This chapter also display the definition of the framework of strategic change initiatives for the health care organization in respect to organizational success in future. Moreover, research questions are also described in this chapter with the help of some research methods as well as the Nature of the Study. Significance of the study and its importance also explained here. This particular part also justifies the framework and clarifies the idea of nature of successful strategic change initiatives for health care organization.

Background

According to Maruthappu et al.  (2013), 2010 has been considered as the most notable year in the history of Health care system. The introduction of the PPACA- Patient Protection and Affordable Care Act and the Health care and Education Reconciliation Act has changed the operating scenario of this sector.  A major social issue of the US is that the rising expenditure in the health care sector. It has been seen that almost within a 40 months interval time the expenditure increases by 1% of the GNP. Ejike-King & Dorsey (2014) has shown that the patients have contributed the only 25% of the entire health care expenditure and the most of the part has been contributed by the third party agencies. The other main problem that forced the changes in the current infrastructure is the incremental number of population in the uninsured section. According to a report published by Maruthappu et al (2013), it can be said that almost 45 million USA citizens are out of the insurance reach. However, the study by Watson (2013) argued that the peoples who are having the medical insurance have used the medical service more than the uninsured peoples have.

The other rising factors that influenced the strategic changes in the health care industry are the segregation of the patients, minimizing the hospital staying time to increase the service for the waiting patients (Kim & Ha, 2013). The segregation of patients started from 1960s this early segregation practice has increased the race-based practice within the sector that is becoming as a harmful practice in the recent days. The other problem is that to provide the health care service to the maximum peoples most of the health and social organizations are minimizing the hospital staying time for the patients. Plunkett (2012) stated that in doing the practice the accuracy of the service is coming down that is increasing the after treatment complexity for the patients. 

According to Welborn & Bullington (2013), the current external changes has raised the question that whether the present management infrastructure of the health care industry has the right competency to meet the challenges raised due to the change in the multiple factors.

According to Maruthappu et al.  (2013), the demand of scale and the demand of service in present scenario has became very much specific and to meet those challenges it requires a specific skills with the management. However, Ejike-King & Dorsey (2014) argued that it is the role and the responsibility of the health and social are organizations to cope up with the changes and to deliver the cost efficient and high quality service to the service seekers.   Research on the strategies and policy changes in the healthy and social care have stated that it requires the development of a strong administration (Simioni & Campello, 2013). However, a complete opposite view on this issue has been framed by many scholars requiring a very specific set of competencies to adopt and deal with the current orientation of the sector (Kash, Spaulding, Gamm & Johnson, 2013); (Wang, Zhou & Yan, 2012).  Within  this context, some of the scholarly studies have stated that in some cases it has been observed that some of the health care organizations do not have this competency to meet the changes in the health care scenario (Maarse, Ruwaard & Spreeuwenberg, 2013). 

According to Leonard (2014) the needs, the demand, and the structure of the present health care industry has changed dramatically and the working principals changed in accordance with the time. Therefore, the required administrative competencies of earlier times and the preset time has a dramatic difference and to ensure the accuracy of the service it is very much important to develop administrative competencies otherwise the organization could face larger trouble in the coming days for its existence within the sector (Parry & Roehrich, 2012).  The ability to acquire new knowledge, understand how to benefit from it, and the challenges linked to the effective use of new knowledge are the criteria necessary for  the health care administrator in today’s environment (Luxford, Safran & Delbanco, 2011).

Statement of the Problem

Ongoing strategic change initiatives in health care require specific management competencies and it remains the responsibility of health care administrators to successfully manage these ongoing change initiatives while delivering high-quality, cost efficient patient health care (Nigam, Huising & Golden, 2014).  Variations in success of strategic change initiatives may be related to an organization's ability to acquire and use new knowledge to ensure successful initiatives (Kash, Spaulding, Gamm, & Johnson, 2013).  Research has recommended the general need for strong management in healthcare settings, however, few scholarly papers provide specific insight into the management process required to successfully manage such change initiatives (Perla, Bradbury & Gunther-Murphy, 2013).

Given the aforementioned challenges facing today’s healthcare administrator, scholars question whether the competencies presently required for these professionals are enough to meet the challenges of ongoing strategic change management in today’s healthcare environment (Parmelli, 2011). Should these ongoing strategic management changes not be addressed successfully the complexity of healthcare management will widen the margin for error and variability in practice- a reality already documented in healthcare management in the United States (Chen, 2012; Seymour, 2012). Consequently, recent research has reported results of inconsistent and failing strategic change management models practiced by healthcare administrators (Greshengorm, 2012; Morelli and Lecci, 2014). The problem to be addressed in this study is that while specific demographics of healthcare administrators has been studied related to strategic change management (Kuiper et al. 2013; Weitzel & VanGorp, 2014), these demographic indicators are inadequate to reveal the specific nature of successful strategic change initiatives in healthcare organizations (Arbab Kash et al. 2014; McAlearney et al. 2013; Moreli and Leci, 2014).

Purpose of the Study

The purpose of this qualitative, multiple case studies is to explore healthcare managers’ perceptions on the nature of their successful strategic change initiatives in healthcare facilities located in the Middle Atlantic region of the United States. A multiple-case study research design (Yin, 2014) will be utilized to meet the purpose of this exploratory research. Primary data will be collected using individual, in-depth interviews with eight healthcare administrators. Instead of an absolute number, Schram (2006) suggested a range of five to 10 participants for a typical qualitative study, claiming that a large sample size could hinder a deeper investigation. The unit of analysis is the healthcare administrator.  The participant selection strategy employed will be a purposeful small sample of using homogeneous participants that is, according to Patton (2002), informational rich.  Results of this study may prove useful to healthcare administrators in healthcare on how to successfully manage ongoing strategic change initiatives.  Data sources used for triangulation will include observational field notes (George, 1990), and a quality audit through subject matter expert (SME) examination and reflection on the data (Patton, 2002).  Triangulation of data sources will be conducted to establish credibility of the researcher’s reflections on the phenomena under study and confidence in the study’s results.  During the analysis stage, feedback from the managers will be compared using cross case synthesis to determine areas of agreement as well as areas of divergence (Yin, 2014).

Research Questions

Heath care managers and policy makers have been having tough times to improve efficiency in hospital setting (Nigam, Huising & Golden, 2014).   Research on developing methods to measure efficiency in the hospital indicates some improvement and consequently the success of organizational change efforts has come a great way (Mutter, Rosko, Greene, & Wilson, 2011)  The healthcare management literature may benefit from a more industry specific examination of success factors related to strategic change initiatives that will assist healthcare organizations in their goal of increasing hospital efficiency while delivering quality healthcare Arbab Kash et al. 2014).

The research questions define the approach for the present study. To obtain the appropriate answer, the right questions need to be asked (Browne & Keeley, 2007). As such, it becomes important to identify suitable questions for the research. Consistent with the purpose of this study, the two research question of this study are as follows:

RQ1:  How do healthcare managers’ perceive the nature of successful strategic change initiatives applied in US healthcare facilities?

RQ2:  How do healthcare managers’ perceive strategic change initiatives that can support delivery of quality healthcare in their healthcare facilities located in the Middle Atlantic region of the United States?

Nature of the Study:

The purpose of this qualitative study is to explore how managers and the healthcare policy developers perceive nature of successful strategic change initiative in their organizations. The research design that will be used to conduct this study will be a multiple-case research design that is exploratory and using face-to-face interviews as a primary source for data collection.  A multiple-case research design was chosen as a framework for obtaining direct evidence from management and other staffs of health care system in Middle Atlantic of United States regarding the effect of strategic change initiative in ongoing health care system (Yin, 2014).  Individual interviews of health care manager will provide depth of information on the perceptions concerning the studied phenomenon in each interviewee’s institutional setting.  For this research project, the researcher will use a multiple-case study to examine several cases to understand the similarities and differences between each case (Yin, 2014 9).  A multiple-case analysis is the ideal research design for this study because it permits investigation of a complex contemporary phenomenon in-depth within its context and with fewer limitations than a survey or experimental design (Yin, 2014).

In the case study, multiple units of analysis must be identified.  A unit of analysis is the phenomenon or population from which information is collected (Yin, 2014).  The units of analysis for this study will be ten health care managers interviewed from different health care organization in the region of Middle Atlantic in United State (Mason, 2010; Yin, 2014).  The number of units selected will be based on a replication approach, and includes participants who represent a single case, as in a scientific experiment.  The outcomes from each case would result in either similar or contrasting results from this study’s initial propositions (Yin, 2014).  A total of ten to 15 cases would be sufficient to support a replication approach that confirms this research’s propositions (Yin, 2014).  Prospective research participants will be selected using both purposeful and snowball sampling (Hatch, 2002).  The collection and use of multiple data sources strengthens a case study and allows for the corroboration or triangulation of data (Yin, 2014).   

The proposed interview instrument will consist of open-ended, semi-structured interview questions.  Data collected through content analysis or interviews will be thematically coded.  The identified themes will be used for data triangulation.  Data triangulation will be used to corroborate facts found within the multiple data sources (Yin, 2014).  To facilitate data management, the interview notes will be organized by the research questions and subquestions.  Themes will be organized by a number and letter combination, with the number referring to the research question number and the letter referring to a distinct theme. 

Thematic analysis will be used to perform the content analysis of interview and documentary data for this study.  Identified themes will be consistent, referenced, and traceable to the data collected.  Keywords will be extrapolated from the data (Yin, 2014).  Identified themes will be consistent, referenced and traceable to the data collected. The analytic technique to be used on the data is the cross-case synthesis so that each individual case will be treated as a separate case, but synthesis of the data of each case will strengthen the overall case study data. Research data collected in individual cases and compared to determine consistency and variance between cases (Yin, 2014). Keywords will be extrapolated from the data. Each theme identified will be analyzed to describe the phenomena being investigated (Yin, 2014).

Significance of the Study:

Changing population demographically and up to date heath care protocols are the main contextual factors in the corporate sector of health care. Apart from that, enhancing the quality of care and labor regulations also associated with the contextual factor in health care industry. Ongoing strategic changes may trigger the organizational process of health care across the world. Nature of strategic change initiatives allows the organization in engaging with multiple initiatives. This study is significant in addressing and offering recommendations for effectively applying changes in the health care sector.   This research will inform administrators and directing boards of how health care organization can move forward positive changing initiatives and serves high quality health care service. Moreover, administrators will benefit from this research with data collected from hospital administrators who have succeeded in implementing successful change initiatives in health care organization and the overall strategic management process including areas such as financial management, financial budgeting, insurance bill payment, negotiation for patient bill payment, etc through a sustainable manner.

Definition of Key Terms

Health- This term refers to the complete wellbeing of an individual in terms of mental, social and physical wellbeing (Frenk & Gomez-Dantes, 2014)

Management- This term refers to coordination of activities done in order to achieve specific objectives and goals through a systematic approach involving a group of diversified or specified people (Drucker, 2012).

Healthcare- This term refers to the care facilitated to an individual to keep the person healthy by a professional or by self is known as health care (Walsh and Smith, 2011).

Healthcare Management- This term refers to management and coordination of activities in order to optimize and enhance the care process ensuring faster recovery from any type of medical condition thus achieving greater success (Walsh and Smith, 2011).

Healthcare Organization- This term refers to organization specialized and authenticated to facilitate health care (Skagert, Dellve and Ahlborg, 2012)

Healthcare Managers- This term refers to managers having leadership responsibility to lead and manage the care system in order to achieve the goals and objectives of health care (Walsh and Smith, 2011).

Health Administration- This term refers to field of health care which deals with management, administration and leadership in maintenance of public health systems, hospital networks and health care systems.

Change Management- This term refers to managing changes in an organization in order to gain control over resistance as well as introduce and approve changes within a particular domain (Swayne, 2013).

Public Health- This term refers to the strategies or approaches made to bring improvement of health in a particular population or any population through organized and coordinated efforts (Swayne, 2013).

Summary

Health care organizations have faced many strategic changes in last few years especially in the last five to seven year tenure. According to Leonard (2014), the changing aspect in the health care policies and the change population demographics has forced the industry to develop new strategies. Ongoing strategic change initiatives in health care require specific management competencies and it remains the responsibility of health care administrators to successfully manage these ongoing change initiatives while delivering high-quality, cost efficient patient health care (Nigam, Huising & Golden, 2014).  The problem to be addressed in this study is that while specific demographics of healthcare administrators has been studied related to strategic change management (Kuiper et al. 2013; Weitzel & VanGorp, 2014), these demographic indicators are inadequate to reveal the specific nature of successful strategic change initiatives in healthcare organizations (Arbab Kash et al. 2014; McAlearney et al. 2013; Moreli and Leci, 2014). The purpose of this qualitative, multiple case studies is to explore healthcare managers’ perceptions on the nature of their successful strategic change initiatives in the healthcare facilities located in the Middle Atlantic region of the United States. This present study draws the example of successful implementation of strategic change initiatives and management literature. A multiple-case study research design (Yin, 2014) will be utilized to meet the purpose of this exploratory research. Primary data will be collected using individual, in-depth interviews with eight healthcare administrators. Cost efficient and high quality care is needed to include in health care service via involving various types of successful strategic changes. However, this particular part demonstrates that this study mainly adopt for exploring the nature of successful strategic change initiatives in health care sector that facilitate the high quality care particularly the organization in the Middle Atlantic region in United State of America. Through the study’s recommendations may inform administrators of health care organization on successfully manage today’s demands of health care organization to deliver high quality healthcare.

 

Chapter 2: Literature Review

Introduction:

In line with the change initiatives taken by the healthcare Institutions; they are certain specific management requirements that need management competencies to reduce cost, delivery high-quality services in offering efficient healthcare services to patients (Nigam, Huising & Golden, 2014).    Strategic change initiatives come with some slight differences that may be related to an organization’s ability to acquire and use new knowledge to obtain successful initiatives (Kash Spaulding, Gamm, & Johnson, 2013.  Healthcare settings in today’s world need strong management to successful manage change initiatives. Most healthcare research coming through scholarly papers, recommends the great need for high quality and strong management (Perla, Bradbury & Gunther-Murphy, 2013)

Success factors related to strategic change management in organizations are well documented in the management literature (Kuipers et al. 2013; Weitzel & Van Gorp, 2014), but they are seldom studied in healthcare organizations engaged in multiple strategic change initiatives (Arbab Kash et al. 2014; McAlearney et al. 2013). Consequently, annual spending on health care and resource allocation in this area far exceed global norms without clear clinical benefit in the patient healthcare delivery (Perla, 2013; Priri 2012).

Documentation

In order to get information that help in developing literature review part, several database such as EBSCOhost, Northcentral University, ProQuest dissertation has been searched. These types of several databases were searched in order to get the information about nature of successful strategic changes in healthcare organization. These types of websites allows in accessing volumes of scholarly articles, journals, trade publications, cited PDF files, dissertations, newspapers, magazines, blogs, etc. In the search list, putting keyword with the related topic such as nature of successful strategic changes in healthcare, strategies for healthcare, need of strategic changes in healthcare organization, etc allowed in getting initial information. Researcher modified the list and revealed most relevant literature with cited file. In order to search the scholarly peer reviewed articles and journals that relates with the topic using the relevant searching keyword within the last five years. In the search box, researcher extended the keyword by outing theories and models including nature of strategic changes, strategic changes initiatives in healthcare. Apart from that, researcher search for literature from the other sources especially from the several articles and journals. Moreover, in order to find the literature, researcher searches in blogs and newspaper in terms of getting relevant and up to date information.

Conceptual Framework

To define success factors, scholars in the change management literature recently viewed hospitals as open systems (Kash et al. 2014).  Open systems are defined as those facing uncertainties in both their internal and external environment, making complex post-modern organizational change literature more pertinent to today's healthcare organization (Meyer & O'Brien-Pallas, 2010).  This study is framed by models of successful change initiatives, which assume change is not linear, or sequentially planned and implemented over time, but rather is an open-ended process requiring adaptation, planned changes and innovative leadership (Burnes, 1996, 2004; Dawson, 1994). In a comprehensive literature review of conceptual models for organizational change three foundational models of successful emergent change, provide the framework for this study:  Kanter, Stein, and Jick's (1992) Ten Commandments for Executing Change; Kotter's (1996) Eight-Stage Process for Successful Organizational Transformation; and Luecke's (2003) Seven Steps. Additionally, Kash et al. (2014), recommends that emergent organizational change models be seen through the lens of Young's (2005) Seven Lessons from the VHA model of empirical research on organizational transformation in the Veterans Health Administration (VHA) system in the early 1990s, which is one of the few applicable studies of lessons learned from the implementation of multiple change initiatives in the healthcare sector (Kash et al. 2014).  Figure 1 summarizes and cross references the success factors for change across these four models. 

Kanter, Stein, and Jick's (1992) Ten Commandments for Executing Change:

According to Kanter et al, (1992), the change irrespective of the sector is multi directional as well as ubiquitous. This indicates that at one time it can be happened to any directions. This process of change is thus more or less continuous process. . According to the theory of Kanter, the operation of an organization is driven by the behavior and attitude of the employees. The change is mainly proposed by analyzing the different behaviors that the employee exhibit and also based on some structural supports. The following three precepts provide a brief of Kanter’s theory of change:

• The informal and the formal sources derives the power

• For meeting the goals of an organization, it is important that the staffs have access to all the resources

• By rising the skills and knowledge of the staffs that can increase the productivity of an organization.

Thus for communicating such changes in the organization, the opinion of Kanter is to share the information in a top-down approach so that every employee in the organization is aware of the changes and the goals of the organization. Sharing ideas or spreading knowledge will lead to staff collaboration and development of innovative ideas that help to improve the performance of the healthcare organization. Thus to foster change within the organization, it is important for the top management to permit the personnel to socialize a bit and also communicate effectively with the subordinates, peers and superiors.  Further, empowering the staffs is also important. Theory of Kanter states that the employees who feel that they have huge workloads and should be rewarded for their efforts and contributions which will help them to support change and also engage in work more.

Kotter's (1996) Eight-Stage Process for Successful Organizational Transformation: According to Kotter (1996), almost 75 percent of any organization’s management is intended to "buy into" the change. This indicates that, individual entity of any organization needs to work exceptionally hard during the first step, and pay out momentous time as well as an energy building exigency, prior to moving onto the next steps.   The eight steps of Kotler involve:

Creating Urgency:  This means examining the competitive and market realities and also identifying and discussing the important opportunities and also potential crisis for stimulating people to sign up for the changes in their organization. In order to change the overall business process in healthcare system first need to analysis the overall structure of the organization. The first step of Kotter’s model allows in identifying the potential scenario and threats that displaying what will be happen in the future. However, the first step creating urgency start to discuss about the convincing reason of changing and talking as well as thinking about the change.  Apart from that, this step of Kotter’s model assists in examining the future opportunities that can achieve by the healthcare organization after change the structure. Beside also, this step examines the features that may exploit the business in future. Furthermore, through creating urgency step of Kotter’s model organization in healthcare industry can track the report of customer’s support and realized the reinforcement of outside investors.     

Developing a guiding coalition: This means assembling a group with power to support and put effort to change, attract the important change leaders by showing commitment and enthusiasm. This will help to encourage the employees to work together in a team and support collaborative change. The second step of Kotter’s organizational change model allows the organization in identifying the true leaders as well as managers. Implementation of Kotter’s model can allow the company in healthcare industry in asking the emotional commitment of their true leaders within the organizational process. Apart from that, guideline of building a team that dedicated to change the organizational workforce help in checking the weakness of the team and make sure that the combination of team member is good and they can able to perform at different levels as well as areas. 

Take initiatives and develop strategic vision: Create a vision for steering change effort and also create strategic initiatives for achieving the vision. The third step of Kotter’s model determines the value of the organization that force them in central changing. Before change the organization process of healthcare industry, it helps in developing a short summary about the future what will happen in the future for the organization. Thus, organization is able to make changes properly according to their resources that make sure them in successful organizational changes. However, in order to execute the vision of the company that helps in leading successfully in future, this step assist in creating appropriate strategy such as extensive care of the patients.   

Converse for Buy-In: This means to build engagement and alignment by sharing few stories. However, it is to be noted that the communication should be heartfelt and simple. Thus communicating the strategies and visions would help to develop new attitude and behaviors. This step of the Kotter’s model helps in addressing the people’s concerns that can allow in achieving successful vision of the organization. Moreover, this part combine the every opportunity with the change vision. This vision can change the organizational process such as change in hiring people, training to the staffs, reviewing employee’s performance, etc.

Staff’s Empowerment for successful change: The fifth step is to empower actions which would help to remove the changing obstacles and also change the structures and systems that may work against the organizational vision. As soon as organization looks for change, this step empowers the staffs along with the ability such as skills and knowledge via identifying change leaders. In order to empower the staffs and maintain successful changes within the organizational workplace provide rewards for changes and recognize the people via removing barriers.  

Developing Short Term Goals: The sixth step of the model is to develop short-term wins which producing, tracking and evaluating consistently the large and small accomplishments volume and also link with the outcomes. In order t achieve success and staying the initiatives changes within the organization, Kotter’s model helps in selecting the extensive project with proper justification. For achieving success, generates simple project for the organization and implement it with the help if critics. 

Stay Persistent: The seventh step is to sustain acceleration that means increasing the credibility for changing systems, polices and structures that may not link with the vision, develop, promote and hire the employees who can execute the vision, reinvigorate the new processes along with volunteers, themes and new projects. Apart from that, Kotter’s 8 step model especially this step motivate the management staffs and helps in analyzing what the reason of success or failure of the business. It can helps in developing appropriate strategy to the organization for generating successful changes initiatives.

Make Change Permanently: Lastly, it is to incorporate the changes in the culture of the organization. This means to articulate the link among the behavior of the employees with the success of the corporate. Making continuous efforts to make sure that changes are seen in the organization will help to change the culture of the organization. This is the last step of Kotter’s eight-step change management model. This pat describe that the overall change permanently. These steps described the stress of successful change management of the organization. Moreover, allows the management in including values in terms of hiring the new staffs or training to the staffs. Apart from that, it is talking about the future progress of every successful change within the working environment. MACPHEE and SURYAPRAKASH (2011) argued that, in order to change the organizational process permanently especially in the healthcare sector need to replace the leaders that generates changes.  

Luecke's (2003) Seven Steps:  The seven steps of managing change and transition by Luecke’s produced a self reinforcing circle of commitment, coordination, and employee competency. The steps include:

Step 1: Mobilize commitment and energy by identifying both the issues that the business is facing and also the solutions. It allows the organization in business sector to develop more commitment with the stakeholders. Thus, they are able to identify the potential problems of the business along with its solutions. Nolan (2011) argue that first step of Luecke’s seven step allows the business marketers in developing great commitment with others.

Step 2: Creating a shared vision for organizing and managing the competitiveness within business process. After developing the shared vision in order to manage and organize business, company can potentially run their business and make firm control over the business that can display the successful change management.  

Step 3: Identify the appropriate leaders for business. One the leaders are identified, business can run successfully in their changed environment because leaders allows them in making quick decision and total control within their business. Leadership will be the effective for any working environment in terms of making quick and effective decision that leads success. Oreg et al. (2013) cited that leaders are the sole of taking responsibility within the business and they also take major responsibility in making exact decision. Apart from that, leadership within business operation pays the major role of controlling the overall business process.   

Step 4: Emphasize more on the short-term results not on the organizational activities. Piercy and Lane (2011) opined that achieving short term goals and objectives successfully allows in developing successful change management. However, short term goals can analyze in better way rather than long term goals. Through short terms goals, organization is able to increase long terms success as well as growth rate. Measurable success also can be achieved by the short-term goals. It is also provides appropriate direction of growing business in a proper way.  

Step 5: The changes should be started from the periphery and then  should be extend to other business units in the organization without pushing it from the top management

Step 6: Institutionalize the success in the organization through structures, systems and formal policies. Appropriate structure and proper policies assists the organization in making success especially during the changes of business.

Step 7: Adjust and monitor strategies to respond to the problem and make effective changes to the system. Monitoring strategy will be the very much effective and efficient way of increasing business quality. Apart from that, it reduces the CRA from clinical organization and the stress that arise during work.  Moreover, it helps in developing better project team integration and setting up the risk based monitoring.

Luecke believes that by implementing these steps a healthcare organization can implement the changes in a better way and also approach a support the changes in a right way with appropriate actions.

Further, it is also noted that all such factors can be taken as the bedrocks of effective change.

Lewin’s change management model is very much effective in order to change the organization. The three step model of Kurt Lewin helps in looking for resistance that derives the habits or the organization.

Step 1- Unfreeze: This is the first step of three-step model. This phase allows the organization in terms of changing there working environment base on their past learning observational and influences of culture. In order to change the organizational workforce, need to change add new force within the operational process. It can help in removing some existing factors and adding some new features within workplace of organization. However, Remesan (2012) argued that unfreeze process has three different sub process such as disconfirmation, previous beliefs and learning anxiety.

Disconfirmation: This part leads with the dissatisfaction of the organizational process. For example, organization in business sector sometime is not able to meet with their goals and objectives. It creates dissatisfaction in their overall business process that may close the business forcefully. Due to larger gap between the exact believed and need to be believed within organizational process, dissatisfaction mainly occur. On the other hand, Saghafi et al. (2011) explained majority of organization in business sector ignored the new information about external environment changes. These changes also create dissatisfaction for the organization.

Previous Beliefs: It is also known as the survival anxiety within the business process. Saji (2012) cited that if the learning anxiety is present, this may not occur or sufficient in building changes of organizational process.

Learning Anxiety: In order to unlearn process, there are several organizations that does not make successful changes in their business. It can leaders the resistance and trigger defensive. In response to learning anxiety, three major stages occur such as shifting the responsibility and scape-goating, Denial and Bargaining.

In terms of changing the organizational process, it is very much useful and necessary. Learning anxiety will be the great method of developing changes within the organization.

Step 2- Moving: In order to change the organization, need to identify the dissatisfaction. After successfully identify the dissatisfaction about the real estate and current condition, moving is an important stage. Samson and Bevington (2012) stated that it is very much important as well as necessary in identifying the exact reason of successful change organization. For starting the changes of organizational process, three possible areas need to covers. These are –

• Identify the exact word that need to change on new or expending the meaning.

• Analyze the concepts of interpretation of the existing business process with the broader context.

• Properly find out the scale of adjustment that evaluate with the new input.

Before moving the business into the new state, required to identify properly about the gaps and disadvantage between the existing business process and future business process. Apart from that, organization has to include the activities along with the imitation of role model that aid in making change. Moreover, in order to establish successful changes, need to personalize the solutions through test and trials learning.

Step 3- Refreeze: This is the last and final stage of Lewin’s change management model. In this stage, it has been seen that new behavioral established successfully and becomes habitual. Apart from that, this part represent organization that change their operational process develop proper identification of their future goals and objectives and new self concept. Moreover, this stage develops the new interpersonal relationship with the others that brings sustainability of change management process.     

Young's (2005) Seven Lessons from the VHA: It provides details of the organizational analysis, strategic implementation plan and communication strategy of the change process. The seven lessons include (Anderson, 2005):

Appoint the right leaders: The transformation of VHA transformations explains that it is important that every organization should hire the leaders whose experiences and personal backgrounds can help the organization to transform in the right way.

Pursue a coherent and focused transformation plan: According to the transformation of VHA, the top leadership team must focus on four initiatives for making an effective changing plan that is vision creation, adopting a latest structure for organization, setting up a proper accountability system and also modifying the rules and regulations.

Persevering in the existence of flaws: According to the VHA transformation plan the leaders, who are focusing on the transformations in the organization should be responsive for legitimating various criticisms.

Matching changes of internal environment with the external environment: The VHA’s transformation plan reveals that the transformations include legal reforms that impeded internal changes. To accomplish the positive changes in the organization, the top management should collaborate with the interests of different parties. Thus the leaders should typically control both the external and internal environment that will contribute towards the substantial successful transformation.

Create and manage different channels of communication from both the levels; highest and lowest of organization: This includes informing the employees about the transformations through meetings or video conferences or written notice etc. This would help the employees to be attentive about the change that is going to happen in the organization.

Focusing on training and education: To allow the organization to proceed with the changes; it is important to train and educate every person in the organization about the transformation and develop their skills and attitude according to the changes.

Balancing the operating unit with the system unit: All the activities and the function of the organization must be reviewed properly and the unwanted things should be removed from the operating units. This decision can be taken by the leaders only who are handling the system. However, they sometimes face issues in making the right decisions. Thus it is important to make the decision structure and requirement decentralized and improve according to the best-fit of  the organization to support change.

Further, this model has also provided training and education to adopt change initiatives.

All the above models indicate that there is has a shared concept of the need for change (Baxter & Jack, 2008; Yin, 2014.  Here, the concept primarily revolves around certain factors like strong leadership, effective communication, involvement of people, and system-wide unity. The first three models (Kanter et al. 1992; Kotter, 1996; and Luecke, 2003) have discovered the consequence of a shared vision and strategies.  It is the fact that whiles the models of Kanter et al. (1992) and Young (2005) explored the need for a well-crafted implementation plan, right at the same time the other two models (Kotter, 1992; Luecke, 2003) depicted the flexibility, empowered action, and the ability to adjust strategy in implementing change.

Similar to above mentioned change management model, that helps the healthcare organization to sustain in this competitive and changing world, recent scholars like Hiatt (2006) and Anderson and Anderson (2010) have developed few models that can also help the organization to manage change effectively. Hiatt (2006) examined the change examples of more than 700 organizations and created the ADKAR model, which initially planned to comprehend change on individual level. It has five building pieces or goals: i) familiarity with the need to change; ii) yearning to take part and help change; iii) information on the most proficient method to change; iv) capacity to actualize obliged abilities and practices; and v) support to maintain the change. He then proposed the change process of Prosci, which has three principle parts: i) planning for change; ii) overseeing change and iii) strengthening change. The primary part contains characterizing change administration system, setting up a change administration group, and creating a sponsorship model. Creating change administration arrangements, taking activities and actualizing arrangements constitute the 'overseeing change' part. The third supposed 'strengthening change' part contains three subparts: gather and examine input, diagnose holes, oversee safety and execute remedial activities and celebrate victories.

Finally, Anderson and Anderson (2010) organized a change methodology model, which comprises of nine periods of action. There are: i) get ready to lead the change; ii) Creating hierarchical vision; iii) duty and limit takes after behind; iv) surveying the circumstances to focus outline prerequisites; v) plan the fancied state, dissect the effect; vi) arrange and sort out for usage; vii) execute the change; viii) commend and incorporate the new state; ix) and course and learn correct.

The Management of Change in Healthcare Organizations

Health care management has been constantly affected by organisational change that is reflected by the growing interest in its research. In between growing prices, major reforms in regulations and policies and evolution of technology, the search for efficient methods and models of directing and leading reforms in keeping their organizations in a sector and industry that is not stable is continued by health care executives (Greenfield, 2011). As answers are searched by the leaders, researchers are interested in the evolution of health care organizations in fitting into the new marketplace (Grol et al. 2013).

The management of change is one of the main concerns of Health care management and hence it is obligatory for the health care professionals to acquire and maintain the skills required to take their professional tasks and only those in which they are competent. Moreover, our surroundings are continuously changing to which our response should be passive, participatory, supportive and indifferent (Al-Sawai, 2013). There is a dramatic increase in the rapidity of the change (Nembhard and Edmondson, 2011).  The process of change management is dynamic, challenging and complex. It is not simply a solution of technology or people but an amalgamation of both. Managing change is all about handling the issues and difficulties that the process is facing. It is all about planning, implementing and evaluating the operations, strategies and tactics and ensuring that the encouraged changes are relevant and worthwhile. Managing change is a challenging, dynamic and complex process. It is not just a choice among the people –oriented or technological oriented solutions but also combination of both the factors (Davies, Finlay and Bullman, 2000).

The characteristics of effective change are namely the introduction of newer ones, unfreezing old behaviours and re-freezing the newer ones. A change may be rare, sporadic, continuous or occasional (Chreim, Williams & Coller, 2012). The response to predictable change is easy because of the available time for preparation while it is difficult to effectively respond to unpredictable changes that are common in the healthcare sector and are very rapid (Parmeli, 2011).

The ability to adapt, evolve and change is the only competitive advantage that can sustain. A variety of factors affect the rates of failure such as the senior management’s lack of commitment and vision, limited linkage with processes  and other systems of the organisation and implementation plans that are ill-conceived (Knaus, 2009). To achieve more success in the efforts of development by organizations, executives and managers have to develop a better way to think about the change and a better understanding of the important points that are associated with the management of change (Grol, 2013). The promotion of change is both fatiguing and demanding. The precedent is challenged by the manager in the process of bringing about change. Perseverance is necessary in going against the norms and habits of the behaviours that are established. The process of bringing change is time consuming and requires the manager to give a large part of his time into this (Law, McCann & O’May, 2011). The manager should focus on changing the values rather than reacting to every situation for change. He/she must act according to what is important (Baker, 2010).

Promoting the changes in an organization is both fatiguing and demanding. The transformational changes in the healthcare organization include changes in the practices, structures and values of the organization. For making all the actors to agree with the contents of transformational changes and its process, it is important to place various factors. Greenwood and Hinings (1996) expand on authoritative components that empower radical change. Their model places the idea of force at the focal point of instruments that encourage or oblige change. As indicated by their system, radical change obliges encouraging and empowering flow. Accelerating flow are inside weights or triggers for change that get from effective stakeholders' disappointment with a predominating layout, and a promise to values that contrast from current qualities. Accelerating motion all alone doesn’t promise that change will happen, and accordingly there is a requirement for empowering flow. Empowering motion comprises of stream of assets from influential gatherings and additionally limit for activity. A vital component in limit for activity comprises of capacity to assemble, which is a sign of initiative.  Change organization can take a top‐down or a bottom‐up course (Balogun and Hailey, 2008). The writing on real change in associations as a rule and in human services frameworks and associations specifically, focus to the part of senior administration in the change. While it is by and large contended that senior administration inclusion in significant change is fundamental (Jick and Peiperl, 2011), it is additionally realized that managerial arrangements and orders can be evaded in medicinal services associations at the clinical level. For instance, Waring and Currie (2009) demonstrate that progressions including managerial difficulties to expert self-governance may bring about circumvention of the managerial arrangement. Mcnulty and Ferlie (2004) demonstrate the points of confinement of radical change that embraces top‐down methodologies in health awareness associations. The isolated nature of practices in health awareness destinations is gone to by Ferlie et al. (2005). These authors point to the integration of groups of practice of wellbeing experts that have a tendency to be self‐sealing and profoundly organized as a component that impedes change obliging joint effort crosswise over expert gatherings. Our case including incorporation crosswise over expert gatherings and associations permitted us to guide administration and different components that help effective.

In any type of organizations, irrespective of their service change is not a welcome move since it can have both positive and negative effects instantaneously. With regard to health care sector, the changes are deep rooted and extensive that encompasses change from lowest status holder to highest. This leads to heavy workload on health care managers for implementation of such change (Moran & Parry, 2003). Resistance has deep roots in human psychology, thus health care sector which revolves round the humans is no different or immune this phenomenon. In these years, a lot many theories and models have been proposed to combat such resistance and implement changes at health care settings. Some of these theories and models have been implemented by health care managers to adjust to changes carried out by organizations. There can be many hurdles to change, but the most important is cognitive aspects of change (Lavis et al. 2005).

The establishment of a clear vision in the change process’s direction is a critical and vital element in the assurance of change that is successful. The measurement and monitoring of the results of the process of change is very essential and important in the recognition of the fulfilment of the purpose for which the change is initiated and carried out. Since change is a continuous process that occurs in an organisation which leads to and results in the implementation of modifications in the organisation itself, it is very essential for the people associated, for instance the staff and other professionals of the organisation, in bringing about the change to focus, evaluate and keep track of the problems and issues that arise in the process of bringing about the change (MacFarlane, 2011). This will aid in preventing the issues and problems in the future in order to allow the new system of administration in helping to manage the change in the most efficient and effective manner (Calhoun et al. 2008).

According to Michael (2011), generally people with whom the organization work with never like changes but it is important to cope and face the changes that are inevitable. Thus it is needed accept the beget progress of change. It is just a general evolution that permits the surroundings of the organization to improve and change. With no change, the healthcare industry can never sustain in this competitive and ever-changing environment. Health care industry must not get stuck with the issues without the x-rays or antibiotics or should not miss the opportunity of advanced technologies that are holding the future. Change is really very hard to accept and some associations or people land up in grieve or sometimes in anger. In case of health care organizations, it is generally the big insurance associations and the government that direct changes. Even though the change is being accepted, it is then about making adjustments. Thus the responsibilities of the top management are to help the teams to support the changes and make them acceptable. Further, for implementing the changes, the organization must get familiar with the hand-on projects. The organization must be clear with the essential objectives and goals and develop a plan that can be used for consulting. Then it is important to critically assess the weaknesses and strengths and various opportunities and threats which would help to apply the resources like new software or equipment or in extra training or hiring new personnel. All these would help to pay attention on the needs of the employees and also develop transform the process into integrated approach. This would help to avoid the roadblocks and also issues that might surround the company. Accepting and managing changes shows that the organization cares for the people and would like to bring in successful improvements to embrace changes in their process.  Effectively maintaining the changes helps the healthcare organizations to support cost-effective care and also provide high quality outcomes, as the people expect from their caregiver to be thoughtful and compassionate. The medical practices that can deliver all these changes will have a competitive edge in the marketplace of healthcare.

Before taking initiative of changes in the organization, it is necessary to recognize and evade the common barriers like:

Cultural scepticism, resistance and complacency: It is important to prepare and expect specific level of dissent. Change is complex in nature and there are various resistances in the organization. Some organization may see change as a necessary initiative while others may be sceptical about the changes as they have already lived with past initiatives. Thus every organization should demonstrate the reason behind any changes and also seek help from outside experts to overcome resistance, build plans to avoid real issues (Rudiak-Gould, 2013).

Lack of effective communication: Through effective communication, organization can avoid misunderstanding that can ultimately hamper the plans. Thus, the best way to avoid miscommunication is to define the vision and goals. Articulating the activities that the organization is undertaking and also honing the messages would help to ensure that effective communication is being conducted among the employees in the organization (Nordvang, Rolland & Simpson, 2008).  

Lack of accountability and alignment: This is one of the major aspects for organizational success. This mainly requires appointing the appropriate management structures and systems and also appropriately planning the changing process phases. By leveraging and assessing the strength and weakness of the organization, an organization can ensure that they are accountable for all the activities that are happening internally (Lange & Coltham, 2005).

Absent or Passive support of leadership: The crucial step towards success is leadership engagement. The best endeavours have had unequivocal backing and association from the executive groups and CEO. This may incorporate expressly going to report-out sessions to survey task results, freely perceiving achievement (Johnson & Klee, 2007). Stroll in the footsteps of the team members to comprehend what they're doing is important as a leadership support.

Overloaded Employees: Resources shortages or heavy workload is some of the common issues in an organization. Introducing new changes can generally become stressful in an organization for overloaded workforce (Burke, 2003). It is the responsibility of a smart leader to communicate the team about the initiative undertaken and also how the changes are going to benefit them in making their live easier. Thus explaining the advantages of rethinking the workflow and utilizing the latest technologies and process for reducing the steps that do not provide any kind of value to the organization would help to encourage and support changes.

Micromanagement: All the leaders in the healthcare organization are responsible for sharing the expected and attained goals with the team. Permitting a control and command approach to prevail in the organization is the best and quickest process to stifle the engagement and innovation from different members of the team. Thus the responsibility of the leaders is to set up proper mission and vision and empower every team members and remove the barriers. Inadequate structures and systems: Ensuring proper structures and systems would help to increase the success of the organization (Savage, Chilingerian & Powell, 2005)

Before taking initiative of changes in the organization, it is necessary to recognize and evade the common barriers like:

Cultural skepticism, resistance and complacency: It is important to prepare and expect specific level of dissent. Change is complex in nature and there are various resistances in the organization. Some organization may see change as a necessary initiative while others may be sceptical about the changes as they have already lived with past initiatives. Thus every organization should demonstrate the reason behind any changes and also seek help from outside experts to overcome resistance, build plans to avoid real issues (Rudiak-Gould, 2013).

Lack of effective communication: Through effective communication, organization can avoid misunderstanding that can ultimately hamper the plans. Thus, the best way to avoid miscommunication is to define the vision and goals. Articulating the activities that the organization is undertaking and also honing the messages would help to ensure that effective communication is being conducted among the employees in the organization (Nordvang, Rolland & Simpson, 2008).  

Lack of accountability and alignment: This is one of the major aspects for organizational success. This mainly requires appointing the appropriate management structures and systems and also appropriately planning the changing process phases. By leveraging and assessing the strength and weakness of the organization, an organization can ensure that they are accountable for all the activities that are happening internally (Lange & Coltham, 2005).

Absent or Passive support of leadership: The crucial step towards success is leadership engagement. The best endeavours have had unequivocal backing and healthcare organization from the executive groups and CEO. This may incorporate expressly going to report-out sessions to survey task results, freely perceiving achievement (Johnson & Klee, 2007). Stroll in the footsteps of the team members to comprehend what they're doing is important as a leadership support.

Overloaded Employees: Resources shortages or heavy workload is some of the common issues in an organization. Introducing new changes can generally become stressful in an organization for overloaded workforce (Burke, 2003). It is the responsibility of a smart leader to communicate the team about the initiative undertaken and also how the changes are going to benefit them in making their live easier. Thus explaining the advantages of rethinking the workflow and utilizing the latest technologies and process for reducing the steps that do not provide any kind of value to the organization would help to encourage and support changes.

Micromanagement: All the leaders in the healthcare organization are responsible for sharing the expected and attained goals with the team. Permitting a control and command approach to prevail in the organization is the best and quickest process to stifle the engagement and innovation from different members of the team. Thus the responsibility of the leaders is to set up proper mission and vision and empower every team members and remove the barriers.  

Inadequate structures and systems: Ensuring proper structures and systems would help to increase the success of the organization (Savage, Chilingerian & Powell, 2005). This generally includes offering the appropriate software or systems required by the staffs, incorporating the appropriate management structure and also implementing the best approach that would help to lead changes. The healthcare organizations must ensure that there exist the basic principles that support change and also flexibility to adapt various situations and also the developing needs. Creating structures and systems based on the expected results instead of the tools that are being used would help the organization to support change.

Lack of control plans for sustaining and measuring results: While implementing something new in an organization it is important to develop a quality improvement program. Having a proper control plan by developing proper mechanism would help to identify the challenges and issues before they hamper the project.

According to the Transtheoretical Model (TTM), every organization needs to follow six stages of changing process (Sarbandi et al. 2013). The following are:

Pre-contemplation: This is the first stage in which the people in the organization are not interested to support change; they deny accepting the problem. The main reasons behind staying in this stage are rationalization, resignation, rebellion and reluctance.

Contemplation: According to this stage the individuals are quite aware of the problem that the organization is facing and are serious about solving the issue. They make commitments to solve the issues through effective actions.

Preparation: According to this third stage, employees plan various strategies as action and make final decisions to support the change that the organization is likely to take.

Action: This is the stage at which the people have already implemented the planned strategies and now they are ready for the change. The changes get recognized and employees put their greatest effort and time to work according to the new changes.

Maintenance: Here the individuals maintain the change momentum and work to consolidate the profits that they gain while implementing the actions and also avoid failures.

• Termination: This is the last stage in which the individuals successfully implement the change.

The following process of change helps the organization and the employees to progress through each stage mentioned above.

Source: (Prochaska, DiClemente & Norcross, 1992)

The nine processes include:

Raise Consciousness: In this process, the people become aware of the challenges and issues and also potential solutions to solve the issues.

Social Liberation: In this process, resources and choices are provided to empower the individuals

Emotional stimulation: In this process, emotions are utilized to energize the individuals that permit people to supersede procrastination and also establish the interest.

Self Re-evaluation: This is all about appreciating the changes that is important for individuals’ success, happiness and identity.

Commitment: Here the employees believe and act upon their own abilities

Countering: It is about substituting the cognitions and behaviour for old working processes

Build Relationship: This means to take the social support for facilitating change

Controlling Environment: This is all about restructuring the situation for eliciting the new behaviour and restrains the old behaviours. 

Reward: Giving award to others or self for the effort being contributed to implement the change.

In conclusion, various global changes are underway that promote individual organisations to modify themselves in a way that they adapt to the change and move ahead successfully. Problems and issues have arisen within organisations that are considered here. There is a need to look into solutions that help in solving the problems and issues that arise due to the continuously happening change around us. To have the proper functioning of the organisation as planned, there should be up gradation in the skills and knowledge of the employees and managers (Stanley, 2011). There should be provision of the required training on the modifications in technology. All issues should be kept track of by the individuals who are responsible for bringing about the change and an ultimate solution should be designed for the betterment of the organisation (Law, McCann & O’May, 2011). 

If improvement in safety, quality and affordability is assured, the change in the practices of the healthcare sector is widely accepted. However, the delivery of healthcare facilities to the immediate population requires fine tuning to their actual needs. It is also very essential and highly required to clear communication and create programmes to provide awareness between the organisation and the public. Also, the speed of change is growing and not slowing down (Moran & Parry, 2003).  The forces that drive the change in the healthcare sector have the potential to produce an enormous economy for those who can implement survival techniques that are effective and efficient in the short term and provide the assurance of success on the long run as well. To achieve the above said goal, the forces that tend to drive the transformation need to be harnessed in the proper manner and be used to enhance to the advantage of the organisation (Calhoun et al. 2008).  Lastly, the change in the services of the health sector implies increasing improvements in the capabilities of the organisation that are currently available, incremental empowerments to the agents of change and providing support to the leaders that bring about change in a manner that is long lasting and continuous (Cherry and Jacob, 2013).

Challenges are involved in the process of bringing significant changes to the programs, goals and routines. According to Anderson, Frogner, Johns & Reinhardt, (2006), it might be very confusing for staff involved in providing medical care patients to accept new technologies and implement new programs. It is essential to know that effective medicine roots effective change management. At the same time it is also the fact that if there is a panicked person, they should be asked to sit down calmly and should be told that you know how it is done (Gaylin, Moiduddin, Mohamoud, Lundeen & Kelly, 2011). Healthcare reform deals with the complex and overwhelming problems that need attention, but meanwhile the smaller things also need to be taken care of. There is a way of practicing it in a more efficient manner.

The Leadership Factor in Successful Change Initiatives in Healthcare Organizations

Various organizations are compelled to develop changes in order to survive in this competitive marketplace. For responding to the rapidly changing environment in global, national and local areas companies must be competent to meet the objectives. Thus change management focuses on pattern of interaction among the people, and also the identity of people. Absence of leadership concentration, poor strategies and structures on the changing complexity will affect the changing process. Thus for making the change management effective in the health care organizations it is important for the leaders to focus on creating  identity of the people in the organization (Beerel, 2009).

The term “leader” is widely used by researchers without understanding the exact meaning of it. In this context, West et al. (2003) demonstrate the significant responsibility that leaders can take part in, is the large-scale change initiatives in health care. According to them, it is describing three broad aspects that can bring improvements throughout the process. It is the fact that all such improvements can take place in terms of gaining positive attitude; enhancing policy for seniors, support towards delivery. Furthermore, a successful leadership strategy also employs a standard national improvement model within the operational procedure of the health care organizations (West et al. 2003).

Leaders generally act as a change agent in the organization. They assist in clarifying the values, vision and mission; identify the policies, structures and strategies. They help in generating efficient process of learning and also facilitate the subordinates to create a mental model for thinking continuously and systematically. Leaders engage the team members to work effectively by encouraging them to participate in the decision making process.  This helps the leaders to develop a sense of belongingness among the team members and motivate them to support change (Johannsdottir, Olafsson & Davidsdottir, 2015).  At the same time the work in Jonkoping County, Sweden, also explores the significance of leadership (Baker, MacIntosh-Murray, Porcellato, & Dionne, 2008), where the diligence, assurance, continuity, approach, as well as a group effort among the Chief of Learning and Innovation, the Chief Executive, even the Head of the Department of Medicine were reflected on the essential entity in provincial makeover.

In today’s competitive situation, various organizations see leadership as the most important contributor towards the performance and change of the organization. Effective leadership always helps to implement effective changes in the organization. Change efforts generally include, silence culture, secrecy culture and the individualism culture. These cultures help to address the issues that may act as barriers in organizational change (Herold, Fedor & Herold, 2008).   Further, it is also noted that there exists a list of studies explored that the explicit leadership activities can shore up change initiatives though employing a wide range of initiatives. As mentioned by Wooten et al. (2006), such factors include employment of number of staff, exploring the idea of the labor force, recognizing the intended populace, assembling the work as a main concern, assigning time as well as resources to attain objectives, and putting organizational goals. Change management is the crucial area, in which the organization must focus on to improve the business. The change management mainly emphasizes on meeting the core-competencies of the business. Thus it is important for every visionary change agents, the leader to be more motivational and skillful. However, the leaders should also be aware that the sometimes changes can affect the leadership capabilities.

The duty of leadership does not end up with the implementation of change in the organization. It is a constant process that the leaders must concentrate on. It is crucial for the organization to develop change management by diminishing the unexpected and expected changes. Leaders are the personality role model in the society. However, there are different styles that are mainly implemented for effective management of changes in the organization. According to the opinion of Lowder (2009), in this rapidly changing and dynamic environment, the transformational leadership is the best style to follow as it emphasizes on development of the organization. Since the change management is becoming the core-competency of health care business leaders, there is a need of visionary leaders who would motivate the employees in the organization. Employees trust is increased by the leadership styles of the top management. This highly motivates the employees to change the behavior of the individuals and also implement various innovations for controlling different affiliation of the departments and also differences in the individuals.   

From another viewpoint, Nadler & Tushman (1990), state that the charismatic leadership style specializes in sustaining and mobilizing the activities within the organization by perceiving the personal characteristics.  With the aims of employing skilled leaders outfitted to monitor positive change, Kash, Spaulding, Johnson & Gamm (2013) appropriately mentioned that the necessary leadership proficiencies required be acknowledging as well as controlling. On the other hand, Baker et al. (2010) suggest that an energetic leader can put relatively more efforts as well as exert a pull of other towering performing person, which ultimately show an elevated level of adoption rate.

In this context, it is noted that the study of Green & Plsek (2002), unambiguously illustrates the leadership proficiencies, which can be examined through employing “diffusion executives”.  Added to this, it is also noted that the enlargement of leadership activities within the health care organization, along with institutional aptitude and competence edification are extensively illustrated in the literature  (ExpandNet, 2009b). At the same time, it is also the fact that the healthcare organizations that performed to an elevated level in several areas in the United States as well as the United Kingdom have empowered methodically with building enhancement ability (Garman, McAlearney, Harrison, Song & McHugh, 2011). Yet, the study of Roski & McClellan (2011) explored the fact that very few staff members (approximately less than 10– 15%) of the National Health Service (NHS) in England vigorously engage in traditional development actions are takinhg place simultaneously. According to this study, further it is also noted that to renovate health care organization’s exiting activities, most NHS staff members (nearly 80–100%) are required to engaged in vigorous development efforts (Roski & McClellan, 2011). Thus, it becomes apparent that much more research is required to draw a significant conclusion regarding whether improvement capability exists and is underutilized (Green & Plsek, 2002) or whether the potential gap is without a doubt large in nature.

In today's era due to advancement in technology, each healthcare organization is attempting to get an edge over its rival and to do so healthcare organizations are obliged to be more versatile towards change. To get together with the difficulties of twentieth century, healthcare organizations are needed to be changed over into learning healthcare organizations at the initial stage itself, so as to become the world class healthcare organization. For change, of a conventional healthcare organization into a learning healthcare organization, the basic obliged requirement is leadership. That can illuminate the vision and mission of the healthcare organization, help the workers to complete their targets and assist them to get settled in new learning and innovative environment (Singh, 2011). Leadership is critical essence for the process of change management as by definition, change requires new framework creation and at that point standardizing the new inventive methodologies.

Primarily the transformational leadership approach is considered as the best leadership style having abilities to addition change completely in a healthcare organization (Eisenbach, Watson & Pillai, 1999). Leaders are the people who have the ability to lead any kind of changes. They need to help the individual to create aptitudes that encourages them to adapt up to the changes. Effective change leaders need to give careful consideration towards the dispatch, usage and maintaining of the specific change exertion (Herold, Fedop & Herold, 2008). Change management is a process that incorporates different aptitudes i.e., authority advancement (capacity of top administration to get trust of inner clients in them), promoting and deals capacity (to make mindfulness about the results of progress) and correspondence ability (assemble help for the choice to change (Kaminski, 2000). Absence of any of these abilities may have awful effect on the adequacy of progress administration transform in a healthcare organization.

As opined by Corrigan & McNeill (2009), there are certain aspects required to hold up organizational / system capacity building. As mentioned them, they are providing right to use for suitable skills, exercise and be familiar with the significant responsibilities of core level managers in accomplishing the revelation and make certain that the front line views are heard (Corrigan & McNeill, 2009).  As identified by Fulton et al. (2011), there are seven skills that make possible for the workforce to enhance both quality as well as productivity of the health care organization at scale. These seven skills are as follows:

1) Process and systems thinking;

2) Delivering on cost and quality;

3) Initiating, sustaining, and spreading change;

4) Involving patients, staff, and the public;

5) Personal and organizational development;

6) Problem-solving/internal consultancy skills; and

7) Innovation for improvement.

However, it is the fact Fulton et al. (2011) fail to advocate which skills are essential at which stage of the organization (Fulton et al. 2011). Thus, certain changes in traditional undergraduate medical learning to integrate enhancement of excellence, exercise point toward a constructive shift in furnishing the subsequent age bracket for large-scale improvement (Rahman, Malik, Sikander, Roberts & Creed, 2008).

Despite the fact that the part of a leader is noticeable in overseeing associations and hierarchical change procedure, however the imperativeness of different elements can't be denied. There may numerous inner and outer powers which have a critical part and influence the situation, while overseeing associations. Organizational culture is imperative in associations and can influence the hierarchical change process. Many organizations proclaim that role of the leader is constrained in making the organizational culture, in this, the organizations’ nature, the geographical region in which an association is located, the representatives and their inclination of work are additionally critical. Moreover the evolving social, political and technological situations can likewise influence in the execution of associations, and hierarchical change process. The part of leader is extremely constrained while controlling and overseeing such elements(Boga & Ensari, 2009)

What Drives a Successful of Process of Change?

A significant portion of the change administration writing spotlights on depicting how supervisors and workers react to change and prompts chiefs and staff regarding how to handle the anxiety, clashes, and intense subject matters that go hand in hand with change, increase help for and cooperation in the change exertion, and by and large make association wide changes less traumatic.  Change is executed by and has results for individuals, and change can be made essentially less traumatic and more effective if these human angles are expected and took care of successfully. It is critical to include representatives adequately in authoritative choice rolling out and improvement activities. At the time of change, stakeholder engagement and effective communication are more imperative than regular and can significantly influence the expense and also outcome for efforts being put for change process. Trust is recognized as especially critical in acquiring backing for and cooperation in change endeavors. Employees and executives see change in an unexpected way: (a) senior supervisors ordinarily see change as an opportunity for both the business and themselves; and (b) workers commonly see change as troublesome, meddlesome, and furthermore prone to include loss. At the point when overseeing change, it is fundamental to distinguish the key issues, for example, loss of turf, connection, importance, future, competency-based personality, and/or control (Project Management Institute, Inc, 2013).

Added to the concept of careful planning, both the leaders as well as managers of large-scale change required to adopt the process of change vigilantly. In order to do so, mostly following three dimensions was used:

1) The extent at which the attempt is vigorously pushing to participants (Ferli and Shortell, 2001);

2) The fundamental change theory that force to do the work; (Johnson & Gamm, 2013) and, 

3) The process of extending the intervention in health care. Greenb & Plsk, 2002)

According to the first dimension as mentioned above, the extent at which the attempt is vigorously pushing to participants can take place in an assortment of ways. This can be in the form of “let it happen”, which is nothing but the process of normal dissemination or may be in the form of “help it happen” or even in the form of “make it happen”, which are commonly known as the vigorous dissemination (Greenhalgh, Robert, Macfarlane, Bate & Kyriakidou, 2004).  In this context, it can be said that most of the examined examples are either in the form of “help it happen” or “make it happen.”

According to the second dimension as mentioned above, the fundamental change theory that force to do the work, a majority of the change initiatives were employed a clear mock-up to do the work. In this context, a well known example of the fundamental change theory that force to do the work is the Model for Improvement (Langley, Nolan, Nolan, Norman & Provost, 2009). At the same time, the example of systems thinking as explored by Perla, Bradbury & Gunther-Murphy (2013) is the process of present thoughts and performance in large scale change initiatives in health care.

In this context, further it is also noted that there are certain programs, taken, for example difficulty in swiftly examining change ideas by means of the “PDSA” format encountered difficulties with the selected theory. That encountered difficulties with the selected theory.  However, it still remains uncertain whether these disputes were in relation to the selected theory or several extra structural aspects, such as, deficiency in motivating the project team (Vos, Duckers, Wagner, van Merode & others, 2010).  On the other hand, it is also true that not any of the evaluated study made any comparison among the existing theoretical approaches. Various studies merely recognized the worth of communal associative thinking that incorporates the use of influential narratives, in health care (Ovretveit & Staines, 2007). 

According to the third dimension of the change initiatives, the process of extending the intervention in health care was employed in a variety of delivery procedures, starting from a small provincial inventiveness that utilized a data-sharing, erudition, and site visits (O’Connor et al. 1996); to an elevated level of collaborative (Green & Plsek, 2002; Jha et al. 2003; Nolan et al. 2005; Schouten, Hulscher, van Everdingen, Huijsman, & Grol, 2008; Vos et al. 2010), to extremely outsized movements (McCannon et al. 2006, 2007; Slade, Tamber, & Vincent, 2003). It is the fact that the efficiency of the change initiatives varied extensively from organization to organization. Taken for consideration, the collaborative methodology fashioned important consequences in the VHA Upper Midwest Coaching as well as Leadership Initiative, in which 26 teams from distinct health care institutions attained quantifiable enhancements in 17 dissimilar study areas (Green & Plsek, 2002). However, it is also the fact that there were ineffective outcomes of this initiative to redecorate the place of work practices as well as monitoring health care activities (Vos et al. 2010).

Summary

Thus, even if the change is fostered, it is necessary for the employees to know the reason of the change and the ways in which they will be affected. Change in the organization may result in confusion, paranoia, insecurities and anger due to the change. The promotion of change is both fatiguing and demanding. The precedent is challenged by the manager in the process of bringing about change. The process of bringing change is time consuming and requires the manager to give a large part of his time into this (Law, McCann & O’May, 2011).  The manager should focus on changing the values rather than reacting to every situation to change. Organisations employing a large workforce of professionals tend not to perform well in case they shoot up their bureaucracy. It should be accepted that management change is continuous. Also, the process of change and the associated problems should be understood by leaders which will allow them to manage and lead change and enhance the efforts (Law, McCann & O’May, 2011).  The success of an organization depends on such informed and inspired leadership (Moran & Parry, 2003).

Associations need to attain to a balance where all levels of administration and staff roles are both ready to change. This gives a noteworthy inspiration to change all the management and staff level. However, measuring and auditing alone won't fulfill change.

Organisations employing a large workforce of professionals tend not to perform well in case they shoot up their bureaucracy. In Steiner’s view, organisations which are hierarchical and bureaucratised tend not to be flexible, allow lesser options for change and empowerment of the staff does not happen. The professional employees won’t be able to provide full value to the organisation if they are asked to do as said. Hence, success can be achieved if change is managed by the leader and not otherwise.  

The most crucial tool in the change management process of healthcare is to engage boards to measure, overview the safety and satisfaction of people engaged with the healthcare organization. The attitude and behavior of the people, team and whole healthcare organization frequently reflect those displayed in team. Changing individuals in persuasive positions can have an impact on the way of organizational culture. A decently organizational change system can change the way of culture of the organization.

A decently outlined organizational goals, vision and mission will help encourage change by keeping up visibility among key stakeholders. In many cases organizations find that a considerable measure of cash has been spent by associations on change programs with little effect or measure. Investing in a change has, to a few organizations, regularly appeared like a bet.

 

Chapter 3: Research Methods

Ongoing strategic change initiatives in health care require specific management competencies and it remains the responsibility of health care administrators to successfully manage these ongoing change initiatives while delivering high-quality, cost efficient patient health care (Nigam, Huising & Golden, 2014).  Variations in success of strategic change initiatives may be related to an organization's ability to acquire and use new knowledge to ensure successful initiatives (Kash, Spaulding, Gamm, & Johnson, 2013).  Research has recommended the general need for strong management in healthcare settings, however, few scholarly papers provide specific insight into the management process required to manage successfully such change initiatives (Perla, Bradbury & Gunther-Murphy, 2013). The problem to be addressed in this study is that while specific demographics of healthcare administrators has been studied related to strategic change management (Kuiper et al. 2013; Weitzel & VanGorp, 2014), these demographic indicators are inadequate to reveal the specific nature of successful strategic change initiatives in healthcare organizations (Arbab Kash et al. 2014; McAlearney et al. 2013; Moreli and Leci, 2014).

The purpose of this qualitative, multiple case studies will be to explore healthcare managers’ perceptions on the nature of their successful strategic change initiatives in healthcare facilities located in the Middle Atlantic region of the United States. A multiple-case study research design (Yin, 2014) will be utilized to meet the purpose this exploratory research and primary data will be collected using individual, in-depth interviews with 10 healthcare administrators.               The research questions define the approach for the present study. To obtain the appropriate answer, the right questions need to be asked (Browne & Keeley, 2007). As such, it becomes important to identify suitable questions for the research. Consistent with the purpose of this study, the two research question of this study are as follows:

RQ1:  How do healthcare managers’ perceive the nature of successful strategic change initiatives applied in US healthcare facilities?

RQ2:  How do healthcare managers’ perceive strategic change initiatives that can support delivery of quality healthcare in their healthcare facilities located in the Middle Atlantic region of the United States?

Research Method and Design

The qualitative research design is appropriate for this study because it will deal with the natural context in an healthcare organization as related to the nature of successful strategic change initiatives..  The qualitative research design is applicable to studying phenomena that cannot be separated from the participant, that is, the participant’s setting, and for this research would involve the principles and belief systems of each healthcare institution in relation to its managers (Hatch, 2002; Yin 2014).  Therefore, this research is bounded by the participants’ setting and the examination will involve complex variables that affect the depth of understanding of the proposed research and evolution of the issues (Yin, 2014).  

The research design fits the purpose of the study in that the context, the healthcare setting, is as important as the researched phenomenon explored which may influence differences in the data collected from participants (Yin, 2014).  The purpose of this qualitative study is to explore the nature of successful strategic change initiative as a viable method of change in healthcare organization.  This research could provide healthcare administrators with significant information to develop strategies for overcoming healthcare administrators’ obstacles and promoting adoption of patient centered treatment methods originating from the area of healthcare administration, such as successful change initiative in healthcare organization.  In addition, examination of the process healthcare manager use and their perceptions in choosing meaningful information, such as change initiative, would provide greater clarity and understanding of the phenomenon within its context.  Qualitative research is distinguishable from other research methods in that the researcher becomes part of a contemporary dynamic situation with the purpose of gaining understanding of the participants of interest within their natural setting (Golafshani, 2003).

The type of qualitative research design that will be used to perform this study will be a multiple-case research design that is exploratory and using face-to-face interviews as a primary source for data collection.  The case study helps with understanding complex issues that involve human interactions and has been used in many social sciences, education, sociology, and for social problems facing the community (Zainal, 2007).  Moreover, a greater number of case studies have been used in instructional situations (Tellis, 1997).  This study will encompass research questions asking “how” healthcare manager perceive change, incorporates recent events in the treatment of patient and technology, and no control by the researcher over participants as they interact in their natural settings (Wahyuni, 2012; Yin, 2014).  The research questions will guide the data collection.  The multiple-case research design will be suitable for the study because the design necessitates analysis, comparison, and contrast of several individual units of analysis, which can lead to the development of analytic generalizations through replication of the findings within the study’s theoretical framework (Yin, 2014).

The multiple-case study approach comports with the purpose of this study for exploring healthcare manager perceptions about change initiative to achieve the goals set out in this research, which could assist with the formulation of strategies to overcome or reduce the perceived healthcare manager’s barriers in managing change.  The multiple-case research study design was chosen as a framework for obtaining direct evidence from healthcare managers regarding the perceptions of the viability of the adoption of change as a helping tool in healthcare institutions (Yin, 2014).  Individual interviews of healthcare administrators will provide depth of information on the perceptions concerning the studied phenomenon in each interviewee’s institutional setting. 

For guiding the collection of data and analysis of collected data will be helpful through the development literature for this particular study. The entire theoretical framework for this study was based on three different foundational models of successful emergent change that is helping in providing a concrete framework of the overall study. The organizatiobnal change models guiding this study are are Ten Commandants for Executive Change (Kanter, Stein, and Jick's, 1992), seven steps (Luecke's, 2003) and Eight Stage Process for successful Organizational Transformation (Kotter's 1996). Apart from that, the emergent change model such as VHA model of empirical research on the organizational transformation is also elaborated here (Kash et al. 2014). In addition to Ten Commandants for Executive Change, seven steps and Eight Stage Process for successful Organizational Transformation model will guide the research, where the adoption decision-process of new innovations proceed from awareness, interest, evaluation, trial and to ultimate adoption or rejection of a product or idea.

The philosophical underpinning of a case study design may be based on a constructivist perspective, where the researcher collaborates with the participants in finding out the story behind the actions undertaken in the participant’s setting (Baxter & Jack, 2008).  Exploration of the participant’s perspectives and the meaning attributed by participants in their work and surroundings become an important part of the investigation (Baxter & Jack, 2008).  The constructivist paradigm is appropriate for evaluating the nature os successful change initiative incorporated in healthcare organization (Gardner, 2012; Ng’ambi & Lombe, 2012).  Moreover, this researcher needs to consider that biases based on the researcher's particular social, economic, cultural, and educational circumstances can cause the research to be skewed (Yin, 2014).  These biases can affect the perspective of the research being conducted.  Nonetheless, the collection of data in multiple-case studies may be affected by the research participants’ experiences and values, which becomes part of the analysis (Wahyuni, 2012).  This research explores the adoption of change behavior from a healthcare manager perspective, whereas many of the available research papers focused on patient attitudes and behavior in the adoption of change (Francom et al. 2011; Keengwe, 2007; Yang, 2010). 

This study is different from previous research efforts on the study’s topic for two reasons.  First, the study is concentrated on the nature of successful change initiative within healthcare organizations and their perceptions of the adoption of change as a viable treatment tool in the healthcare setting.  Second, the study is significant because of the perceived link between healthcare manager perceptions and the adoption of patient centered treatment methods.  In addition, the exploration of the possible reasons healthcare administrator primarily rely on the lecture method is warranted, including the slow evolution towards alternative treatment methods in the field, such as the delivery of content through change (Francom et al. 2011; Watts & Schaur, 2011; Yang, 2010). 

For this research project, the researcher will use a multiple-case study to examine several cases to understand the similarities and differences between each case (Yin, 2014).  The interview process of healthcare manager will help this researcher obtain information regarding the perceptions of change adoption, which include manager willingness, the effectiveness of the treatment method, and the barriers to adoption change initiation in the healthcare settings.  The personal interviews will be useful for understanding opinions, experiences, attitudes, and the processes used by healthcare manager in patient treatment methods (Rowley, 2012).  A multiple-case approach is the ideal research design for this study because it enables the in-depth investigation of a complex contemporary phenomenon within its context and will be less limiting than a survey or experimental design (Yin, 2014).

In the case study, multiple units of analysis must be identified.  A unit of analysis is the phenomenon or population from which information is collected (Yin, 2014).  The unit of analysis for this study will be the individual healthcare managers.  A total of ten Healthcare Managers will be chosen to interview.  Data sources used for triangulation will include observational field notes (Katz, 2014) and a quality audit through SME examination and reflection on the data (Patton, 2002).  These different data sources will supplement the individual interviews about the research questions and the topic of nature of successful change initiative in healthcare institution (Gardner, 2012; Moryl & Jiang, 2013).  The motivation of the participants and their behavioral actions (Wahyuni, 2012) become important in the research and the details will be recorded and analyzed from different perspectives through interviews, observational field notes (George, 1990; Katz, 2014), and SME examination of and reflections on the data.  Triangulation of data sources will be conducted to establish credibility of the researcher’s reflections on the phenomena under study.

The number of units selected will be based on a replication methodology and includes participants who represent a single case, as in a scientific experiment.  The outcomes from each case would result in either similar or contrasting results from this study’s initial propositions (Yin, 2014).  A total of ten to 15 cases would be sufficient to support a replication approach that confirms this research’s propositions (Yin, 2014).  Unlike sampling in quantitative studies, where a sample is selected from a population, each unit of analysis represents a single study and the facts will be gathered from replication in order to predict similar results or contrasting results based on theoretical propositions (Tellis, 1997; Yin, 2014).  Purposeful sampling is appropriate in this research for selecting participants who belong to the field and the subject to be studied (Morse, Barrett, Mayan, Olson, & Spiers, 2002).  Prospective research participants will also be selected using snowball sampling, where informants identify each other as good candidates for the subject studied (Hatch, 2002).  Therefore, in this study, healthcare managers who are responsible for decision making will be selected. 

The proposed interview instrument will consist of open-ended, semi-structured interview questions.  The semi-structured interview is a common interview technique that centers around six to 12 pre-established questions and is a simpler design than research questionnaires developed for surveys (Rowley, 2012).  Data will be collected through content analysis or interviews and coded thematically.  The identified themes will be used for data triangulation to corroborate facts found within the multiple data sources (Yin, 2014).  Informed consent from the interviewed participants will be necessary.  The protection of privacy and safeguarding of proprietary records collected with use of a chain of evidence would enhance reliability and should ensure the study is conducted ethically (Yin, 2014).

Through analysis of the data collected, a pattern may evolve that supports the theoretical propositions posited in this research and lends greater support to the outcomes (Rowley, 2002).  To facilitate data management, the interview notes will be organized by the central research question and sub questions.  Themes will be organized by a number and letter combination, with the number referring to the research question number and the letter referring to a distinct theme. 

Thematic analysis will be used to perform the content analysis of interview and documentary data for this study.  Identified themes will be consistent, referenced, and traceable to the data collected.  Keywords will be extrapolated from the data (Yin, 2014).  Identified themes will be consistent, referenced and traceable to the data collected. The analytic technique to be used on the data is the cross-case synthesis so that each individual case will be treated as a separate case, but synthesis of the data of each case will strengthen the overall case study data. Research data collected in individual cases and compared to determine consistency and variance between cases (Yin, 2014).

The stages for replicating this study’s research design, which may be used by other researchers, include the design of a multiple-case approach that will focus on ten participants from 10 healthcare institutions in mid Atlantic region  in USA.  Each participant response will be used, contrasted, and compared to identify themes and will be corroborated with this researcher’s field notes and SME evaluation and reflection of the data (Yin, 2014).  Each participant selected will be a healthcare manager of healthcare institution.  Analysis of the data collected will ascertain the link to the Ten Commandants for Executive Change (Saji, 2012), seven steps and Eight Stage Process for successful Organizational Transformation model (Parmelli et al. 2011) to check for consistency and differences (Rowley, 2002; Yin, 2014).

Population

The healthcare organization takes the responsibility of providing higher quality health care service to the patient all over the world. Apart from that, the healthcare organization have to take the responsibility of increasing the quality of care within their organization better and involve latest technology that allows the employee in testing patient’s health within short time and provide effective result (Crowther and Lancaster, 2012). However, target population for this research work was the managers of health care organization in the Middle Atlantic region in United State. Apart from that, researcher also selected healthcare facility administrator of healthcare industry in Middle Atlantic region in United State in order to get more information that helps in building this study effectively. The population of this study was 240 managers of the healthcare industry out of more than 2879 managers that represents numerous departments of healthcare industry (Va.gov, 2015). For this particular study, the selected size of population helps in representing good category in terms of generating facility.

Sample

Sampling Criteria: This particular research work will utilize the purposeful sampling methodology in term of selecting the administrators for collection of information.. However, researcher conducted interview in terms of generating relevant response that helpful for designing the study properly as well as efficiently (Denzin and Lincoln, 2011). The sampling strategies of the researcher were to align the respondent’s information according to the purpose of the study. Apart from that, sampling strategies allowed researcher in gathering the available resources and taking the resources into consideration. Furthermore, Bergh and Ketchen (2009) argued that sampling strategies aware the researcher in order to face the constraints in terms of collecting information from the selected respondents.  

Purposeful sampling criteria was used by the researcher in order to select the respondents inaugural manner for this multiple case study including managers and employees of different health care organization in Middle Atlantic in United State. However, employees will be chosen who are working as full time basis in the health care organization for this study (Cooper and Schindler, 2010). According to the researcher, employees who are working as part time basis may provides fake or irrelevant data or information to the researcher that will harmful for the study. However, purposive sampling criteria was selected in order to select the respondents as a part of interview within the large sized organization in health care industry. Apart from that, purposive sampling criteria also allowed the researcher in generating knowledge about the issues that being studied within the research work (Corbetta, 2009). Change initiatives provide the guideline to the management of the health care industry that guess the future prospect of change process. However, there is several correspondents’ report that does not meet with the actual result of the research work. This is also another reason of selecting purposive sampling criteria for this study. Bellamy (2012) argued that in order to conduct a research study primary data or raw information is more effective and efficient rather than secondary data. However, Al (2013) suggested that secondary data helps in getting information about the research study, but primary data provide exact information that concludes the study properly. Researcher selected the participants for this research work from all aged groups individuals, different background such as medical staff, nurse, doctor, cleaning staffs, accountant, administrator, etc and different nationalities.

A purposeful sampling allows the researcher in taking in-depth interview of the selected respondents. However, for this study, researcher with the help of purposive sampling criteria takes in-depth interviews with the managers of healthcare organization in Middle Atlantic in United State. Moreover, purposive sampling also allows the researcher in taking interviews of the selected employees of health care organization in the region of Middle Atlantic in United State. According to Bernard (2011), purposive sampling criteria also allow the researcher in taking in-depth interview of selected people within the single large size organization as well as the multiple organizations in one region of country. The entire respondents of this study provide the exact ad relevant information that useful for conducting data analysis for the research work. Researcher also selected different types of medium in order to take interviews of the respondents such as face-to-face interview, interview over phone call, feedback form, video calling interviews using technologies like Skype, Google Plus, Facebook, etc (Burns et al. 2008).

Sampling Strategy: In this study, researcher selected purposeful sampling technique in order to select the respondents in an inaugural manner. Filip et al. (2012) argued that purposive sampling methods has the ability of selecting respondents where large sized participants available. In this particular study, researcher selected purposive sampling strategy in order to get information from the rich sample size within the region of Middle Atlantic in United State. The aim objective of this study is to understand the nature of successful strategic change initiatives that allows the health care organization in Middle Atlantic region of United State. Gobo (2011) acknowledged that for analysis the unit or individual participants, this sampling strategy is very much effective. However, unit analysis using the purposive sampling strategy allows he researcher in selecting large sample size in a perfect manner. The goal of the researcher in order to select the purposive sampling strategy was to select the participants intentionally regarding the needs and requirements of the study. According to Goodson et al. (2012), purposive samplings used in ensuring the participants are selected from that managerial population of large size industry. Therefore, researcher selected purposive sampling strategy in order to select the managerial population of large size as well as small size organization in health care industry especially in the region of Middle Atlantic in United State. Apart from that, purposive sampling strategy provides the teacher in selecting the require sampling time in order to conduct the interview that fulfill the goal of the research and establish the work successfully. Moreover, purposive sampling strategy also allowed the researcher in building trust of the participants of the research that addressed the answer of the researcher questions in-depth analysis (Guo et al. 2011). In this study, researcher interview more than 150 employees of health care organizations in the region of Middle Atlantic in United State and 240 managers of the same organizations. Conducting the interview, researcher was able to develop close relationship with the participants and meet the goal. Thus, researcher enhanced the validity with details analysis of this particular study. Moreover, though using the purposive sampling strategy researcher was able to in-depth inquiry in a naturalistic setting and generating appropriate outcomes of the study.

Researcher was conducted a field test for this research work after approval the study from the Institutional Review Board of North-central University. It helps the researcher in demonstrating the applicability and dependability of the developed research question and the collection of data or information techniques of the research work. In order to confirm the applicability and validity of research work, researcher selected the four respondents through snowball sampling and purposive sampling technique (Jagodzinski and Wallin, 2013). The participants of the pilot study were recruited according to the selection methods and criteria of the study. The total respondents for the full study were 390 (150 employees and 240 managers of health care organization. This point helps in dictating the selection of available participants for this study.

Sample Selection: After the approval from Institutional Review Board of North-central University (NCU), researcher received the permission of conducting the study on the topic of nature of successful strategic change initiatives in health care organization. This was a multiple case study that conducted via analyzing the factors within the region of Middle Atlantic in United State. In order to select the participants for this research study, researcher prefer for those respondents who are already experience these types of interview or experience in the same phenomenon (Patel et al. 2011). Apart from that, according to researcher, need to select those participants who are willing to provide information or shows their intense to be a participants. The selection criteria for this study was the participants including all members of health care organization of the Middle Atlantic region who have an information as well as understanding about the issues that relates with the multiple case study. All the participants were selected for analyzing researcher of taking interview according to the assumption rate of the participants regarding diversify opinions and views.

Materials/ Instruments

In order to collect the information from the selected respondents, researcher used open ended and semi structured interview procedure. Each and every important subject that relates with the selected topic was received a letter of introduction and request for answer of the question to the participants. Apart from that, researcher used consent form for gathering information from the large size selected respondents. Moreover, researcher provided e-mails to the personal email account of the selected respondents in order to inform the respondents about the interview time and schedule. The main aim of the interview was to understand the nature of successful strategic initiatives within the healthcare organization for future strategic change management. Researcher also mentioned clearly to the participants through e-mail that interview may lasting not more than 25 minute. However, for this particular study, when researcher collected information via interviewing the people of health care organization of Middle Atlantic in United State, three main protocols was maintained such as –

a) An Opening: In this protocol, researcher welcome the participants and identify the key objectives

b) The Body: In this protocol, researcher posted the question for interview to the participants

c) The Closing: It is the last protocol where researcher summarized the identification and information that gather from the respondent including own thinking of the researcher Perry et al. (2012) argued that in order to start a standard data collection process, researcher has to develop different types of interview that support the study. Therefore, researcher selected online interview, face-to-face interview for the respondents ad alert them early about the scheduling and timing of interview. Through this process, researcher was able to develop a chance of getting appropriate information that deviation the process. Moreover, researcher collected the information from the point of view of manager’s perspective. In order to evaluate gathered information, researcher implements the managerial opinion of the environment via creating the non-threatening atmosphere as well as conversational questionnaires. Apart from that, researcher creates formal line inquiry during the collection of data from the respondents. Regarding validation purpose of the study, researcher posed the interview questions and designed using the summative and formative input. Popping (2012) explained that formative evaluation in designing question for data collection is one of the most useful and valuable method from the point of view of improving activity, programs and behaviors. On the other hand, Salaberry and Comajoan (2013) acknowledged that summative evaluation allows the people in final determination of activity, program and behavior in a specific point of time.

According to the researcher, the Part A of the interview guide provided the information including participant’s information such as job title, department of work, age of the employee, work duration within the industry, identification number, contact id, employee id, etc. The part B of the interview guide demonstrated the interview questions that selected to generate information about the nature of strategic change initiatives in health care industry from the perception of management staffs of the health care organization in Middle Atlantic in United State. The question that set up for interview mainly aimed to understand the nature of strategic change initiatives within the health care industry. Apart from that, the part C of the interview guide was the additional data on successful of strategic change management in health care service. However, researcher provides the guideline to participants to respond freely and their first thoughts with the questions (Supino and Borer, 2012). In the part D of the interview for conducting this study, that guideline was to explore the nature of successful strategic change initiatives that helps in successful change management within the health care industry. The nature of successful change initiatives was developed by using the Status Que change management model for understanding the nature of successful change initiatives within the healthcare industry. All the participants were instructed to provide the information freely according to the questions.

Apart from that, according to the instruction of Institutional review Board of North-Central University field testing of interview guide taken place for this formative interview development process. According to the version of question that comes from the Dissertation Committee members, researcher obtains the feedback about the strategic change initiatives and successful strategic change management process. Moreover, researcher allowed the managers of the different health care organization for reviewing the entire instrument that ensure the questions are understandable for each level of the staffs. Through face to face interview, researcher obtained the summative input with the subject matter experts who have the practical experience in this field (Tang et al. 2013). The subject matter experts were selected for checking the all instrument of large size health care organization. Within the research study, the main purpose of the formative and summative information evaluation was to set up the questions that are relevant with the selected topic. Apart from that, according to the researcher, formative and summative evaluation process was designed for ensuring the validity as well as reliability of the questions of interview that used in this study. Apart from that, in order to increase the reliability and validity of this study, researcher selected three main protocols such as an opening, a body and a closing. Moreover, researcher also used the standardized format also maintained that ensure the process of interviews remains same (Sekaran and Bougie, 2012). Moreover, in order to get more idea about the nature of successful strategic change initiative, researcher taken the response from employees and managers of the different health care organization in the region of Middle Atlantic in United State.

Researcher also conducted the pilot study for this work after getting the approval from Institutional review Board of North-Central University. Pilot study allows the researcher in confirming the dependability and applicability of the developed research questions as well as the technique of data collection of this research. Through the purposive and snowball sampling technique, researcher selected the participants. Moreover, researcher also applied the same technique in pilot study. Researcher developed group interview as well as the individual interview for collecting primary data that was called the semi structured of this particular study. Moreover, researcher carefully designed the adequate coverage for the research purpose. Researcher clearly identifies the goal of the pilot study and clarifies the wordiness of the developed question.  The participants who are selected for the pilot study in this research work were not interviewed in the full study. Apart from that, researcher does not include the data with the full study that are collected from the pilot study. The pilot study was conducted in first before making the interview question for the full study. Therefore information that generated by the researcher through pilot study helped in making the interview question as well as improve the quality of question during the first second and third round interview. The particular method and process was aided the researcher in producing better instrument.

Moreover, researcher developed the open-ended interview question for this study in order make the certain alignment between the statement of problem and purpose of the study. In order to ensure the high level of consistency during analysis stage, researcher asked the question to the selected participants in a proper interview format. During the interview process, researcher explores the additional follow up question in order to get ideas and discovers the selected topic. Through the interview question, researcher proved the relevance of investigation of the study.

The developed questions that are selected for this study were properly formatted and using appropriate grammar. The questions are written using the easy and simple language that allows the participants in understanding comprehend (Tang et al. 2013). Moreover, the set up question was developed without bias information and attract the respondents in providing answer with according to the questions. For this particular study, researcher organized the questions in a logical manner. The entire respondents who are selected for interview were asked in a same way. In order to get information for the central position of this study, researcher set four questions. Apart from that, researcher also developed more than 8 questions in order to support the finding of the central questions for this study. In spite of that, researcher set up subsequent sub-questions that also support the finding of the central questions.

During the interview, researcher aligned the interview questions in a logical manner that covered the whole topics along with the literature review part in this multiple case study. The first interview question of this multiple case study that developed by the researcher was – Do you agree that nature of successful strategic change initiatives in health care organization helps in developing effective change management process in future? In reply to this question, majority of manager said that nature of strategic change initiatives allows the health care organization in future successful planning. Therefore, this information used by the researcher in order to shows the relevance of successful strategic change initiatives that already described in the literature review part. With the help of this question researcher was able to show the effectiveness of strategic change initiatives especially in the health care industry without bias information. Moreover, through this answer, researcher provided a clear explanation about the nature of successful strategic change initiatives within the study.

According to Tang et al. (2013), strategic change initiatives allows the high as well as low level management within health care industry in making effective plan for future growth and implement change procedure that may help them in providing better health care service to patients. Apart from that, successful strategic change initiatives assist the management of restructuring the organization and improving the flows of information within health care industry. Moreover, Sekaran and Bougie (2012) argued that nature of successful strategic initiatives motivate the staffs and clarify the decision rights for health care organization. With the help of the answer that provided by managers of different health care organization in the region of Middle Atlantic in United State, researcher list up 17 traits where each correspondence has more than four building blocks that generates the effective execution. The traits that are found out in this multiple case study were flow of information across the boundaries or the degree of the organization, motivating the entre employees via providing rewards and job position according to their performance.

The second interview question of this study was – How far you agree that nature of successful strategic initiatives restructured your organization? In reply to this question, the managers of the health care industry in Middle Atlantic region described that nature of strategic change initiatives are the most effective method for heath care organization in terms of restricting the operation process. Successful strategic change initiatives help in understanding the urgency of restructuring with the proper analysis of current competitive market. Moreover, strategic change initiatives allow the management in identifying group or individual member that supports the oppressions via showing the enthusiasm and commitment. Nature of strategic change initiatives develops the strategic vision for the health care organization that is most important in restructuring the business. Apart from that with the help of strategic change initiatives, management empowers the operational process in order to remove the obstacles and restructure the overall system according to the vision of the organization.

The third question of this study was – how would you feel that strategic change initiatives empower your health care organization rather than other? This question used in order to assess the benefits of strategic change initiatives that empower the operational process of the health care industry. Nature of successful strategic change initiative relates to empower the operational process of health care organization. In addition, through this question researcher also identified that conceptual foundation of strategic change initiatives within the health care organization. The key strategic change initiatives were examined properly through this question within the health care industry that empowered their operations. This research proposed that creating urgency, developing short terms wins and sustain acceleration are able to empower the operational process of the health care organization in all level.

The fourth question of this study was – do you believe nature of successful strategic change initiatives helps in emphasizing more on the short-term result of health care organizational activities? The response of this question was used by the researcher in this study in order to explore the nature of strategic change initiatives that emphasize the short term results of organizational operation in healthcare industry. Nature of successful strategic change initiatives focus on achieving short terms results of the health care organization. Apart from that, nature of successful strategic change initiatives generates wide range of ideas that concerned the management of health care industry about their enthusiasm and commitment employees. In spite of this, it is believed that nature of strategic change initiatives would be achieved the functional requirements of health care organization and identified the leadership or group that has better commitment with the organization. Motivating those groups, health care organization attains their short-term result of organizational activities in a health care firm (Tang et al. 2013). In spite of this, it has been believed that nature of successful strategic change initiatives would allow the health care organization in achieving the higher level of success as well as emphasizing more the short term outcomes in the activities of organization.

The response of the question – How far you agree that strategic change management can fix the problems and make effective change in your organization? Was used in understanding the change management approach of the heath care organization. The response of the managers regarding this question was that nature of strategic change initiatives allowed them in tracking the overall activities within the health care organization and monitor the working performance of the company. This response was used to access the importance of nature of successful strategic change in important decision making and monitoring within the work place of health care organization. However, the response of this question was specifically used strategies that helps in effective change management in system, but not used in the outcome of the study. This research question propose that monitor and adjust strategies in responds to the problems that exists within the work place of health care organization in Middle Atlantic in United State as well as make effective changes for the activities of operational process.     

The response of the question sixth in this study – do you think that nature of strategic change initiatives helps in creating share vision and managing the competitiveness?, was used in accessing the information about development of shared vision and management of competitiveness of healthcare organization through strategic change initiatives.

During the time of interview, researcher used digital recorder in order to collect the data of capture the response of the interviewing people. After completion of the interview, researcher transcribed the interview session and developed the outcome in a significant way. Apart from that, researcher interprets the result with the actual literature for further analysis.

In this particular study, when the researcher is interviewing the selected respondents, gains the greater understanding of the measurement that helps in maintaining accuracy during the research work. Thus, researcher makes the study reliable and valid.

Once the Institutional review Board of North-Central University approved method of conducting research on analyzing the nature of successful strategic initiatives in the health care organization, researcher started the interview and data collection phase. Therefore, in this multiple case study researcher selected the descriptive phase of data collection and also selected the interpretation for representing the analysis form of foundation. In the initial phase of this multiple case study, data collection process are conducted in terms of extracting data or information that are already made, developed the conceptual framework due to happen interpretation and also the researcher dawn the deduction based on findings in terms of generating significance of the study. However, this multiple case study is typically bounded by the time and activity of the university. Apart from that, according to the guideline of the researcher, researcher had to responsible in order to collect data with the use of several techniques. In this multiple case study, researcher conducted the data collection procedure based on the response of selected participants via developing the semi structured interview questions.  During the case study, researcher uses the multiple resources of information during the collection of data that explore the historical value as well as the attitudinal issues that relates with the phenomenon of the study. Researcher collected data through the in-depth interviews for this particular multiple case study. This helped the researcher in generating statistical information demographically. Through the researcher process, researcher gathered the field notes that are very much relevant and effective for this study. In order to make the field work, field notes are one of the most important data collection techniques that used in this case study in terms of recording information as well as communicate the findings of research with the actual literature. The examination of Subject Matter Expert of this particular subject helps in evaluating the research result with the actual purpose of the study in proper format.

Moreover, with the help of Subject Matter Expert, researcher was able to conduct the interview along with the instrument. Based on the reflection of Subject Matter Exert on this particular subject, researcher collected unbiased information or data as well as the objectives in the phase of analysis. However, in order to conduct the interview for collecting unbiased information from the managers of health care organization in the region of Middle Atlantic in United State, researcher taken the permission of director of human resource department of those organizations. Apart from that, researcher provided individual e-mails to the personal email account of the selected respondents in order to aware them for the schedule of interview earlier. Moreover, researcher only taken the interview of those people who willing to provide information. For the face-to-face interview, researcher selected location and invite the people to come on that particular place of those who accept the mail. The purpose of the interview method is to collect the basic information of participants in order to confirm the legality of age and eligibility of the respondents within the study.  Researcher selected attempts in order to organize the selected respondents from each department of health care organization. Researcher uses several approaches for ensuring the managers are participated from all department of the health care industry such as admin department, head of the department of medical team, nursing department, etc.

Before starting the interview, participant has to fulfill the minimum requirements that pose the attitude and opinions based on experiences. After identified that managers from each department of health care organization, researcher send the Latter of Consent form to the participants via emails in order to respond positively. However, researcher selected only those participants who signed the form and accepted the schedule of personal interview. Moreover, after identified the subject from the point of forward participants, researcher referred the participants by number instead of name due to reminder of the study. It helps in maintaining the confidentiality and anonymity of the selected respondents. Researcher only asked the question that relates to identify the nature of successful strategic change initiatives within the health care organization.

However, researcher never asked to the respondents about the proprietary or confidential information about the health care organization. Apart from that, researcher also ensures that each participant was asked the same questions during interview. Moreover, researcher also ensures that the developed questions are made with proper maintaining of emotion of the respondents. Furthermore, researcher also provides the methods of interview to those individuals who are willing to participate in the interview process. In order to ensure discrimination in researcher work in this multiple case study, researcher disqualified the participants due to several factors such as gender, age, religion, cultural background. In addition, the entire participants were designed trough the numerical classification.

Moreover, after completed the interview, researcher sent the electronics copies of the research to the participants of different health care organization of the Middle Atlantic in United State.

Researcher created the comprehensive case study database in terms of replicating the case study that was absolutely necessary. In order to calculate the information and stored in a specified format, researcher used the Microsoft Excel spreadsheet. Through the Microsoft excel spreadsheet, researcher stored information and organized in an efficient format that helps in tracking effectively or easily later. Apart from that, excel spreadsheet also used by the researcher in scheduling the meeting with the selected respondents when researcher conducts the ace to face interview.

In this multiple case study, data also collected through the content analysis. Triangular process also used by the researcher in order to identify the themes of the topic as well as compare the source of collection that strengthening the trustworthiness. Including brief qualitative survey, data sources are used for triangular process. Moreover, researcher used the thematic data analysis technique for performing the content analysis of documentary data or the data that collected from interview. Apart from that, researcher involves thematic analysis in order to identify the patterns, meaning, themes, and ideas of the project. Moreover, the data analysis of this research relies the evidence regarding data collection and the major rival interpretations. Researcher used the cross case synthesis for aggregating the result within the case study. Smith (2011) argued that it is one of the most analytic techniques.

In terms of protecting the privacy of gathered data, researcher do not collected the proprietary information of health care organization in the selected region. Alphanumeric code is used in order to track the participants.

 

Data Collection, Processing and Analysis

Principles of data collection to be followed include the triangulation of the information from interviews, field notes, and SME evaluation.  The data collected will be recorded and transcribed for each case to Microsoft Excel.  The software will be used to document frequently occurring themes, constructs, and meanings to detect patterns across the participant interviews.  The Microsoft Excel database will provide organization of the data for analysis and will include the observational personal field notes to corroborate the evidence.  Data sources used for triangulation will include observational field notes (Katz, 2014) and a quality audit through SME examination and reflection on the data (Patton, 2002).  The personal field notes can be important to provide a commentary of the research process and for identifying differences and similarities in the perceptions of the participants (Eisenhardt, 1989; George, 1990).  The personal observational field notes can also offer a method of overlap to capture this researcher’s perceptions during the research process (Eisenhardt, 1989; Katz, 2014).  The chain of evidence should clearly link to the research’s propositions and cite the relied upon data whether field notes, interviews, or SME evaluation (Rowley, 2002). 

The case study database and the chain of evidence protocol that ties to the research questions help to ensure construct validity and the study’s reliability (Gibbert, Ruigrok, &Wicki, 2008; Yin, 2014).  The use of replication logic will be the basis for establishing notable patterns for analysis and for developing generalizations (Rowley, 2002; Yin, 2014).  The collection and use of multiple data sources strengthens a case study and allows for the substantiation of the data (Yin, 2014).  Data triangulation enhances a study’s construct validity by the use of multiple sources and the strategies for collecting data from the sources (Gibbert et al. 2008).

Furthermore, during study when researcher conduct the work or design this multiple case study, considers several questions in order to show the sufficient support of the study. Moreover, researcher not only set up the question that support sufficient the case study but also provide the answer with the relation to the question that make the study more efficient and reliable (Alvesson and Sandberg, 2013). Majority of researcher fails to implement sampling criteria properly in order to conduct the study more acceptable and efficient with the help of qualitative study. Researcher typically achieved the data saturation during the collection of data. Researcher do not obtained any new information of change the information according to the requirement of the study when the data already amassed for this study (Love, 2012). Apart from that, researcher does not provide the any understanding that relates with the study.

Therefore, researcher considers the data saturation during the definition of qualitative study. Regarding the data saturation, sample size is most important and creates value for the study. In addition, researcher also keeps in mind the necessity if translating data as well as information that improve the quality of analysis and interpretations. During the study, researcher firmly focused on desired outcome of the study and this approach help in conducting research work with better analysis (Novikov, 2013). The Sample size that selected for this study was very much effective and allowed the researcher in in-depth analysis via understanding the entire phenomenon within the study. Wide range of sample size allowed the researcher in investigating the broad scope for this study. However, for this research work, researcher used sampling criteria logically and designs the multiple case studies with the use of relevant information that gathered or collected from the selected respondents.

Chan et al. (2011) cited that judgment of choice and discretionary of the research is the most effective part that need to replicate by the researcher in terms of getting successful purpose that explore the materials of the study. For this research work, researcher explores the study with the help of using how and what types of question to the managers and employees of the health care organization in Middle Atlantic in United State. This was also help in perceiving the relationship between the effectiveness of current and future strategic change management. However, researcher using the how understands the nature of strategic change initiatives within the health care organization in Middle Atlantic in United State. Chen et al. (2012) stated that in order to generate useful outcomes from the study need to more focus of exemplary research such as what, how, when, why, etc. It might be able to generate possible outcomes that relevant to the multiple case studies. Therefore, researcher with the help of prior knowledge and using what, how and why exemplary, generated possible outcome in this study.

Moreover, the number of replications adds to the consistency of the research, supportive of the generalizations that can be constructed from the evidence collected (Rowley, 2002).  A case study that is generalizable can provide an explanation for theory and is said to exhibit external validity (Gibbert et al. 2008).  The replication logic to be utilized in this study provides a framework of inductive reasoning, where the specific phenomenon can be used to draw analytical generalizations and help in understanding the reasons as they might relate to use and adoption of change (Eisenhardt, 1989).

Prior to data collection and beginning the interview process, Institutional Review Board (IRB) approval will be needed from NCU.  The IRB committee will review this proposal to ensure compliance with federal regulations governing human subjects research and that ethical principles are followed (Committee on Science, Engineering, and Public Policy [CSEP], 2009).  The prospective participants will be contacted via email, in-person or by telephone.  An introductory letter that states the purpose of the research will be delivered to the identified study participants.  Once a positive response to the letter (see Appendix A) has been received from the participants, they will be asked to fill in the Letter of Consent form (see Appendix B).  The NCU informed consent form (Appendix B) is required for informing participants of the risks, research purpose, withdrawal rights, and includes a statement of record confidentiality. In this multiple case study, researcher used the replication logic in order to demonstrate the specific selection criteria. Apart from that, replication logic also allowed the researcher in demonstrating the identification and solicited individual participants of the case study.

Moreover, in this study the selected respondents were the current employees and managers of health care organization in the region of Middle Atlantic in United State. According to the researcher, large amount of participants can help to conduct the study with specific information. Corti (2012) suggested that less respondents provides less information that might not be able to unfold huge amount of information that required in order conducting a successful study. Moreover, long interview with one participant may be harmful regarding collection of information. Craige and Unterwald (2013) argued that in health care industry managers of staff of the organization are too much busy with their work. Therefore, ling term interview may provide fake information and also may irritate the respondents. On the other hand, short interview is very much effective and it helps in collecting effective and relevant information from the respondents. Therefore, researcher selected wide range of sample size that allowed them in taking short term interview and due to wide range of respondents researcher was able to collect relevant information through various types of questions. During the collecting of new data for this particular study, saturation was defined from different point of view. Creswell (2014) depicted that if the saturation level does not meet with the research study, it never provide the further light or create greater understanding in terms of investigating the relevant information of the selected topic.

Validity and Reliability

It is the fact that qualitative research is generally considered as being consistent because such study revolves around previous scholarly research studies. Whenever, the validity of any research work is intended to evaluate, there is requiring assessing the end result of the study is whether true and certain or not. Here, the end result of the research study is true means, the research is sufficient enough to reflect the current situation in an appropriate manner. On the other hand, the end result of the research study is certain means, the research work provide further evidences in line with past research studies (Guion, Diehl, & McDonald, 2011). In this specific case, the researcher intended to evaluate two precise validity aspects such as the face validity and content validity.

Sekaran and Bougie (2012) presumed that validity is the major aspects in qualitative research work from the point of view of social science and contested term. In order to generate validity in qualitative research work, researcher has to observers from different sides and different angel. In this present study, researcher conceptualized the validity from the viewpoint of qualitative research. In order to increase validity in qualitative research work, researcher identifies the common characteristic as well as the types of validity.

Validity and reliability in qualitative research differs in meaning compared with its application in quantitative research.  A key difference is that the kind of knowledge obtained in qualitative studies relates to the setting or context in which the phenomenon resides (Yin, 2014).  The researcher may be at the center of the researched activity, an integral part of the process studied, such as in the conduct of a case study (Yin, 2014).  In this research study, data will be obtained from interviews of healthcare administrators and inclusion of the evidence into this researcher’s personal journal to source the activities.

Typically, in the quantitative tradition, validity and reliability are associated with facts or phenomena that can be measured as part of observed reality and the methods for data collection and analysis may involve statistics, which may separate human involvement or interaction with the subject matter under review Golafshani, N. (2003).  Although, validity and reliability are a well-established part of quantitative research studies, these concepts are important in qualitative investigations to ensure credible, transferrable, dependable, and confirmable outcomes, all of which reflect trustworthiness (Golafshani, 2003; Morse, Barrett, Mayan, Olsen, & Spiers, 2002).  This case study’s research design will include multiple sources of evidence, a Microsoft Excel spreadsheet database to organize and trace data to the sources, and sharing of information with research participants (Yin, 2014).  This will assist in obtaining valid and reliable outcomes.

 Qualitative studies often employ the validity and reliability concepts together.  Qualitative researchers are interested in whether a study is credible, accurate, and transferable; the quality of the research is important and reliability is a consequence of validity (Golafshani, 2003; Morse et al. 2002).  Similar to quantitative research, a qualitative study demonstrates its quality if the findings can be generalizable and the tested results increase the validity or trustworthiness of the study (Golafshani, 2003).  The use of triangulation combining multiple sources of evidence in this study will provide a strategy for improving the validity and reliability of the research.  Data collection and interpretation will involve personal interviews, focus groups, supporting documents, and a systematic link to discovered content in a consistent, traceable manner. 

The use of Microsoft Excel spreadsheet software will be used to store research data and organize themes.  A database of the collected data can enhance the reliability of this study by providing a link to referenced evidence obtained from supporting documents, notes, and interviews (Golafshani, 2003; Yin, 2014).  The various sources of data that converge on the facts and help answer how healthcare managers’ perceive the nature of their successful strategic change initiatives in healthcare facilities located in the Middle Atlantic region of the United States should improve construct validity in this case study (Yin, 2014).  Triangulation can not only be helpful, but also appropriate for arriving at a sought outcome including a deep understanding of the phenomena and can help assure validity and reliability (Golafshani, 2003). 

Additional strategies to enhance the study’s trustworthiness will be to use a personal journal throughout the process to write personal reflections of the collected data from the interviewees and the two focus groups.  Member checks may be performed by sharing this researcher’s notes and information with the participants.  This will allow for the possibility that additional data may develop to corroborate the findings (Baxter & Jack, 2008).  Any gaps discovered in the data can be incorporated to obtain a better understanding of interview responses (Baxter & Jack, 2008).  Allowing the participants to review the information reported from the interview and focus group process will address the issue of construct validity by confirming the investigator’s perspective of the case (Yin, 2014).  If the operational measures align with the concepts developed from the case study questions then construct validity is increased (Yin, 2014).

Assumptions

With the help of several assumptions, this case study was founded. The most important assumption of this multiple case study is selected participants provide accurate and relevant data as well as opinion about the nature of successful change initiatives in health care organization. Apart from that, participants were willing to participate in interview. This is another assumption of this study.

Limitations

The main limitation of the study is the weaken identification a study. The key limitation of this case study is that researcher selected several organization in healthcare industry in the Middle Atlantic region. Therefore, wide range of respondents had to select that provides bias information in the study. However, the exploration of the purpose of the study was deemed important. Moreover, researcher was not able to replicate the research in a given date as well as unable to compare the results with the findings.

Delimitations

In this particular case study, the main delimitation was large amount of participants from the healthcare industry in Middle Atlantic region in United State. It provides the bias information into the study. Therefore, researcher was not able to generalize the entire populations of the health care industry. There is also another delimitation that present in this case study was the narrowness of scope. This relates to the fact of particular case study that focuses on the healthcare industry.

Ethical Assurance

 In order to conduct this case study, researcher properly followed the all steps that ensure the professional and ethical behavior along with the intended purpose of protecting the participants. Apart from that, researcher ensures the honesty and rights of privacy amongst the professionals. With the permission of Institutional Review Board (IRB) from North-Central University, researcher collected that data. Before sending the Consent Letter from to the participants, researcher takes the permission from IRB. Moreover, researcher kept the participant’s form in locked file cabinet.

Researcher reassured the participants about the protection from harm. Moreover, researcher also ensures that this study is voluntary and identities would protect. The participants are employed from the large sized of health care organization. This ethical method ensures that participants are protected from harm in this multiple case study.

Additionally, researcher implements the ethical assurance process for avoiding the deception with the participants. Researcher employed the consent practices for ensuring the associated risk of understanding of the participants. Researcher sends the emails to all individuals who are willing to participate with this study before conducting the interview. The entire interview questions were approved with the Informed Consent Form.

Summary

The purpose of this qualitative, multiple case studies will be to explore healthcare managers’ perceptions on the nature of their successful strategic change initiatives in healthcare facilities located in the Middle Atlantic region of the United States. A multiple-case study research design (Yin, 2014) will be utilized to meet the purpose this exploratory research and primary data will be collected using individual, in-depth interviews with 10 healthcare administrators.  The participant selection strategy employed will be a purposeful small sample using homogeneous participants that is, according to Patton (2002), informational rich.  Data sources used for triangulation will include observational field notes (Katz, 2014), and a quality audit through subject matter expert (SME) examination and reflection on the data (Patton, 2002).  The case study techniques has been proposed by Eisenhardt and Graebner (2007), Siggelkow (2007), Yin (2014), along with other past researchers, with the aims of addressing the areas that are multifaceted as well as self-motivated in nature or where further research requires to be executed, as is the case with the present research work. At the same time, the case study approach is also appropriate to understand strategic changes where laboratory environment do not acquiesce suitable outcome (Baxter & Jack, 2008).

At the end, it can be said that the reliability aspect is in association with the selected interview approach and also intended to enhance in certain ways. Here, the validity as well as reliability aspects can be evaluate through employing triangulation, which amalgamates matters from gathered data (Golafshani, 2003). Again, with using tape during interview session and then transcribing the recorded versions in a methodical way will also enhance the reliability aspect of the interviews in this qualitative research work (Creswell, Hanson, Plano, & Morales, 2007; Langley & Royer, 2008)

 

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Appendix A:  Annotated Bibliography

Meyer, R. M., & O'Brien-Pallas, L. L. (2010). Nursing services delivery theory: An open    

system approach. Journal of Advanced Nursing, 66(12), 2828-2838.

This paper focuses on elucidating the how Nursing Services Delivery Theory can be derived from the application of open system theory in case of the large scale organization. The healthcare organizations are referred to the open systems which can be characterized by the transformation of energy, negative entropy, differentiation, dynamic steady state, co-ordination, integration and equifinality. According to the Nursing Services Delivery Theory, it can be proposed that the input, throughput as well as the output factors have significant impact on the global wok demand.  The theory provides a relational structure in order to reconcile disparate streams of research works associated to nursing, staffing and work atmosphere.

Al-Sawai, A. (2013). Leadership of healthcare professionals: where do we stand? Oman Medical Journal28(4), 285.

This paper scrutinizes various leadership theories in context of the health care service. According to the author, various healthcare theories, frameworks and cases have significant influence on the present leadership strategies in healthcare.  In order to ensure effective leadership emphasize must be given on the dynamic relationship among the leadership values, organizational culture, situation and its capabilities. Leadership development is a critical aspect and the major role of the leader is to ensure an instant supply of replacement leaders for maintaining organizational progress in the dynamic healthcare environment. 

Chreim, S., Williams, B., & Coller, K. (2012). Radical change in healthcare organization: Mapping transition between templates, enabling factors, and implementation processes. Journal Of Health Organization And Management26(2), 215--236.

This paper has focused on scrutinizing the element of radical change through mapping the difference between two templates of healthcare service delivery. It has been found that the transition from one template to other is associated with significant change in terms of system, structure and values.  The procedures for enabling change are associated with the potential discontentedness of the stakeholders with the present template and the commitment for a new template; desire to change resources, manipulation for the incentive programs and provision for the credible leadership.

Knaus, M. (2009). Understanding and Managing Change in Healthcare. Journal Of The Dermatology Nurses' Association1(1), 55--56.

According to the author change is significantly affecting each aspect of human life and adoption of proactive approach is effective in managing change. Due to various economic challenges the healthcare industry has been encountering rapid as well as intense change. It has been identified that the preliminary factors triggering transformational changes are effectiveness, efficiency and profit. These challenges are indicating the need for restructuring the health care industry. The industry is facing difficulty in dealing with the change in the economics form supply side to the demand side. Consumerism is also a major factor that has leaded to informed decision making.

Law, J., McCann, D., & O’May, F. (2011). Managing change in the care of children with complex needs: healthcare providers’ perspectives. Journal Of Advanced Nursing67(12), 2551--2560.

The paper has studies the role as well activities of the nurses and other healthcare professionals who will provide care to the children having complex needs. Major challenges have been identified regarding the communication and information systems, family centered care, equity of service provision and partnership working. Additionally, it has been found that the generic as well as specialized skill and knowledge is required. Adoption of partnership working will be effective if set of criteria is developed for judging the future service provision.

Lavis, J., Davies, H., Oxman, A., Denis, J., Golden-Biddle, K., & Ferlie, E. (2005). Towards systematic reviews that inform health care management and policy-making. Journal Of Health Services Research & Policy10(suppl 1), 35--48.

The paper has recognized that the positive interaction between the healthcare policy makers and the researchers help in enhancing the prospect of researches. The findings of the research has identified that it will be beneficial to have relevant information for making decision and reviews. It has been found that the contextual factors were hardly emphasized.

Calhoun, J., Dollett, L., Sinioris, M., Wainio, J., Butler, P., Griffith, J., & Warden, G. (2008). Development of an interprofessional competency model for healthcare leadership. Journal Of Healthcare Management53(6), 375.

Interest for competency based performance system has rapidly grown in order to enhance the organizational as well as individual performance in healthcare industry. This paper has scrutinized the procedures and results associated with the Health leadership Competency Model (HLCM). The model includes psychometric tests, behavioral event interviewing and cross industry sector benchmarking. This model assists in recognizing the opportunities in order to improve leadership in healthcare context.

Scott, T., Mannion, R., Davies, H., & Marshall, M. (2003). The quantitative measurement of organizational culture in health care: a review of the available instruments. Health Services Research38(3), 923--945.

This paper focuses on reviewing the quantitative instruments for measuring the culture and change in culture in healthcare service. It has been found that 13 instruments were found to be satisfying the inclusion. The instruments have been found to be varying in terms of length, grounding theory, format, scientific properties and scope.

Hinctea, C., Mora, C., & cTicluau, T. (2009). Leadership and management in the health care system: leadership perception in Cluj County children’s hospital. Transylvanian Review Of Administrative Sciences, (27E), 89--104.

In the western part of the world, healthcare reform has been a major topic. In Romania significant changes took place in the healthcare service industry. This paper focuses on identification of the important managerial component and role of leadership in facilitating the change. It has been found that the legal framework of a nation is a significant managerial component. Additionally, leadership plays a major role in the healthcare service. Development of effective leaders has been a major challenge for the healthcare organizations.

Anderson, G., Frogner, B., Johns, R., & Reinhardt, U. (2006). Health care spending and use of information technology in OECD countries. Health Affairs25(3), 819--831.

In 2003, the United States had less number of doctors, practicing nurse, and intense care bed days every capita than the average nation in the Organization for Economic Cooperation and Development (OECD). By the by, U.S. spending every capita was just about over two times of the every capital expenditure by the OECD nation. One proposal for both bringing down expenditure regarding healthcare and enhancing quality is to adopt the Health Information Technology (HIT). The United States is found to be lagging as much as 12 years behind other countries which have adopted HIT. In these countries, the national government had played a significant role in order to establish rules and the health insurers had borne the maximum cost.

Gaylin, D., Moiduddin, A., Mohamoud, S., Lundeen, K., & Kelly, J. (2011). Public attitudes about health information technology and its relationship to health care quality, costs, and privacy. Health Services Research46(3), 920--938.

The paper focused on understanding the attitude of Americans regarding the potential of health Information technology in enhancing the health care and difference in their attitudes on the basis of technological affinity and demography. It has been found that majority of the respondents favored that utilization of electronic medical records as they believe that it would help in improving care and reducing cost. Americans trust that adoption of IT in healthcare service will be effective in enhancing service quality and safety.

West, M., Borrill, C., Dawson, J., Brodbeck, F., Shapiro, D., & Haward, B. (2003). Leadership clarity and team innovation in health care. The Leadership Quarterly14(4), 393--410.

This paper has emphasized on analyzing the relationship among the leadership clarity, innovation and team procedure in the context of health care service. It has been identified that the leadership clarity has significant association with the lucid team objectives, higher level of participation, strong commitment to excel and the relevant support for innovation. Team procedures have anticipated the team innovation and team leadership has forecasted innovation. Hence, clear leadership is required for achieving innovation.

Garman, A., McAlearney, A., Harrison, M., Song, P., & McHugh, M. (2011). High-performance work systems in health care management, Part 1: Development of an evidence-informed model. Health Care Management Review36(3), 201--213.

Significant emphasis has been given on the individual performance for improving the overall health care service. This paper has identified a conceptual model which is comprised of 14 types of management practice and nine major factors are influencing the adoption as well as perceived sustainability of these practices. The results of this research can assist in helping the practitioners in conceptualizing management practices as a part of the broader system. It will help the health care professionals in prioritizing the efforts leading to improve the management.

Roski, J., & McClellan, M. (2011). Measuring health care performance now, not tomorrow: essential steps to support effective health reform. Health Affairs30(4), 682--689.

This paper has focused on describing a distributed data approach in order to compute the performance outcome while providing adequate privacy to the patients. Strategy has been developed for implementing the performance measures. A new framework has been introduced in this paper in order to achieve the goals of enhanced patient care and advancement in the performance measurement.

Corrigan, J., & McNeill, D. (2009). Building organizational capacity: a cornerstone of health system reform. Health Affairs28(2), 205--215.

The health care service framework of US need to be redesigned. It has been found care is divided, hazardous, and not efficient. In order to elevate performance organizational capacity, adequate expertise along with inclusion of IT is required. The capacity of organization is strengthened through clinical reconciliation. The development of new organizational structures will increase the chances of upgrading the payment programs and invest capital for developing high-performing frameworks.

Fulton, B., Scheffler, R., Sparkes, S., Auh, E., Vujicic, M., & Soucat, A. (2011). Health workforce skill mix and task shifting in low income countries: a review of recent evidence. Hum Resour Health9(1), 1

The paper has recognized that the task shifting can be considered as an important policy for helping to resolve the issue of workforce shortage as well as imbalance in skill mix. The challenges of task shifting include safety issue, professional resistance etc. It is found that task shifting is potential policy in increasing the productive efficiency of the healthcare service and it will also increase the number of service for a particular quality and cost level.

Rahman, A., Malik, A., Sikander, S., Roberts, C., & Creed, F. (2008). Cognitive behavior therapy-based intervention by community health workers for mothers with depression and their infants in rural Pakistan: a cluster-randomized controlled trial. The Lancet372(9642), 902--909.

This paper focuses on the integrated cognitive behavior therapy in rural areas of Pakistan and it had assessed the impact of intervention in case of maternal depression and outcomes for children. This paper has found that the psychological intervention provided by the community based health workers have significant potential for integrating into the health system in the cases where resources are scarce.

Bate, P., & Kyriakidou, O. (2004). Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Quarterly82(4), 581--629.

This paper has reviewed various literatures in order to study how innovations can be diffused and sustained in the health care service industry. It has defined the diffusion of innovation and the procedures for measuring it have been discussed. In this paper an evidenced based and parsimonious model has been considered for diffusion of innovation in context of healthcare industry has been presented. Additionally, an effective methodology for reviewing the policy of healthcare management has been discussed.

Perla, R., Bradbury, E., & Gunther-Murphy, C. (2013). Large-Scale Improvement Initiatives in Healthcare: A Scan of the Literature. Journal For Healthcare Quality35(1), 30--40.

This paper has provided a comprehensive review of the literature regarding the present approach and practice relating to the large scale improvement proposals in the healthcare service industry. This paper has recognized for major factors that is pertaining to the change initiatives. The factors are: the procedure of change, planning, evaluation of performance, individual, group, organizational and the system factors.

Ovretveit, J., & Staines, A. (2007). Sustained improvement? Findings from an independent case study of the J"onk"oping quality program. Quality Management In Healthcare16(1), 68--83.

This paper has focused on analyzing various quality methods adopted by hospitals.  Jönköping is a renowned example of successful program for improving systems in the healthcare sector. In order to elucidate the value of the program and helps others in learning form this program, this paper has gathered some data from a case study of 2006. It has demonstrated how the  Jönköping program was implemented.

Evans-Lacko, S., Jarrett, M., McCrone, P., & Thornicroft, G. (2010). Facilitators and barriers to implementing clinical care pathways. BMC health services research10(1), 182.

It has been found that the health policy report of the government will help in increasing the efforts for promoting the utilization of care pathways in NHS. This paper has identified that the care pathways can help in proving the expectations of the patients. Additionally, it helps in evaluating the progress of the patients and contributes in promoting teamwork in a diverse work group. Care pathways focus on facilitating the use of guidelines and it can also act as a base for the payment system in healthcare organization. This paper has suggested that multi-faced interventions which can incorporate every people associated with providing health care service must be considered for implementation of care pathway. 

Nigam A., Huising, R., Golden, B. (2014), 'Improving Hospital Efficiency: A Process Model of Organizational Change Commitments ', Medical Care Research and Review, 71(1), p.21-42

It has been observed that improvement of the hospital efficiency is considered to be a major objective for the healthcare managers and the policy makers. Coaching program has found to be an effective initiative which involves external people which aims to enhance the efficiency of the healthcare organizations. This paper has focused on the role of subjective understanding in order to shape the initiatives for improving efficiency. It has been observed that the dynamics of the contested and the strategic framework has helped in shaping the changes in hospital commitments. It has identified the factors that have contributed in enhancing the success of the change initiatives.  

Birken, S. A., Lee, S. Y., & Weiner, B. J. (2012). Uncovering middle managers’ role in healthcare innovation implementation. Implement Sci7(1), 28

In the healthcare service and management research, the middle managers have obtained little consideration. This paper has found that they may have a significant role in executing the healthcare innovation. The gap between evidence of efficient care and the healthcare practice may be ascribed to some extent to poor execution of the healthcare innovation. Examining the role of middle manager in context of execution of healthcare may uncover an opportunity for the elevation. This paper has focused on describing the important role of middle managers in implementing the healthcare innovation in the healthcare service organizations.

Vos, L., Duckers, M., Wagner, C., van Merode, G., & others,. (2010). Applying the quality improvement collaborative method to process redesign: a multiple case study. Implement Sci5, 19

In the context of strategic change initiative, this study evaluates how quality improvement collaborative support to implement such strategy. As per the findings of the study, it is noted that implementation of strategic change initiatives is still remains uncertain as because quality improvement collaborative cannot determine where the disputes were in relation to the selected theory or several extra structural aspects, such as, deficiency in motivating the project team. This study also concluded that essential prerequisites for successful employ of the quality improvement collaborative or QIC method were missing in the context of strategic change initiatives.

Colquitt, J.A., Scott, B.A., & Le Pine, J. (2007). Trust, trustworthiness and trust prosperity: A meta-analytic test of their unique relationships with risk taking and job performance. Journal of Applied Psychology, 92(4), 909–927

In the context of large scale strategic change initiatives in the health care this study provides a conceptual framework with a continuum of spread comprising hierarchical control. As per the research work, it is noted that system thinking is required to present methodological as well as practical challenges faced by health care organizations. This study also indicates that several confounding factors such as fidelity, adaptation latitude, time, etc. are the basic apparatus for health care strategic change initiatives.

This research study explores an all-embracing literature review through concentrating on the specific question, how can we extend as well as maintain improvement in health service deliverance and control mechanism? At the same time it also taken into account both substance (eliciting as well as assessing the dissemination of innovation in organizations) and procedure (examining the literature in a methodical along with reproducible technique). Further, this research work explores (1) a prudent as well as evidence-based model for allowing for the dissemination of innovations in health service organizations, (2) comprehensible acquaintance gaps where additional research should be listening carefully, and (3) a full-bodied and transportable methodology for methodically reviewing health service policy and management.

Moen, P., Kelly, E. L., Tranby, E., & Huang, Q. (2011). Changing Work, Changing Health Can Real Work-Time Flexibility Promote Health Behaviors and Well-Being? Journal of Health and Social Behavior52(4), 404-429.

This particular study explores the action of perinatal melancholy is a public-health main concern for the reason that of its high commonness and involvement with disability and poor preschooler maturity. This study also incorporated a cognitive performance therapy-based involvement into the schedule work of community-based primary health workers in rural Pakistan and assessed the effect of this intervention on maternal depression and infant outcomes.

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