ADKAR: A systematic method for implementing change successfully

Venkatesh R. Bellamkonda, MD

In 2010, when I served as a chief resident, our leadership group mandated resident attendance at weekly didactic conferences. This was felt to be necessary given poor attendance rate and the detriment our resident knowledge (and board passage rate); not to mention, the impact to presenters. We did increase conference attendance, but at a tremendous cost to the unity of our residency.

In 2012, I was the director of emergency ultrasound and became aware that our equipment was not generally clean. Sometimes there was dry blood on the transducers in the trauma bays. Despite real empathy from my staff, my emails were ineffectual at reminding everyone that we need to clean the machines…the dried blood and infection hazard persisted.

I have failed in implementing changes in many ways…has this ever happened to you? How can we implement changes without paying a significant emotional toll? Jeff Hiatt, founder of Prosci and creator of the ADKAR model, described five stages that people needed to achieve to completely buy into and accomplish lasting change: (1) Awareness, (2) Desire, (3) Knowledge, (4) Ability, and (5) Reinforcement. Helping the people that need to implement a change go through each of these stages and giving them time to do so has been well worth my effort in subsequent attempts to effect change.

Awareness begins with thinking about the problem. What is the real problem? What is the consequence of not changing? It is best to begin to make people aware of the problem when you begin to analyze its root cause. This gives people time to digest that there is an issue to improve or that the leadership is evaluating alternative options.

Why should people want to change? Understanding the Desire of the people who will be the ones changing is essential. This requires a baseline understanding of your teams. What resident-centered reason is there for my colleagues to attend didactic religiously? Why should a nurse or physician care that the ultrasound equipment is clean and how does it make THEIR life better to ensure it is clean? I have paid the price for overlooking this key step many times. Communicate why people should fix this problem. Give people time to reflect on the situation.

Next, in the Knowledge stage, unveil the change. The pitfall here is not reaching each of the people who you need to change in the way they need to be reached. If someone does not know how to use a piece of equipment vital to the new workflow, your effort will fail. This may require hands-on demonstrations, practice opportunities, question-and-answer sessions, video guides, or even 1:1 training sessions.

Simultaneously, evaluate the existing system to look for ways to increase your constituency’s Ability to change. If I spent time discussing with the leaders in off-service rotations why the emergency medicine residents will need to leave their posts to attend didactic conference and provide reminders for the off-service faculty to this issue, my residents will have an easier time executing the change. They may also see my efforts to make their lives better/easier, and our relationships will be strengthened by my advocacy. Basically, the idea is to make it easier to change than to stay the same.

Lastly, Reinforcement is accomplished by reiterating each of the ADKAR stages. Engage individuals who continue to be resistant in order to identify what stage they need support with. Indeed, my experience is that people are rarely insubordinate or recalcitrant for the sake of being so. It is also important to be very explicit and objective about the health of the change (e.g. How often are the machines clean after the change?).

On a final note, avoid the temptation to write a single email containing all the needed information of ADKAR – remember that each stage requires time. The exact amount will vary depending upon how significant the change is, and how ingrained the culture or behavior is that you are aiming to modify.


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