The current issue and full text archive of this journal is available at

www.emeraldinsight.com/0952-6862.htm

IJHCQA
21,5 Stakeholder approach for
evaluating organizational change
projects
418
Antti Peltokorpi, Antti Alho and Jaakko Kujala
Department of Industrial Engineering and Management,
Received 5 December 2006
Revised 22 May 2007 Helsinki University of Technology, Finland
Accepted 7 June 2007 Johanna Aitamurto
Director of Nursing, Päijät-Häme Hospital District, Lahti, Finland, and
Petri Parvinen
Department of Industrial Engineering and Management,
Helsinki University of Technology, Finland

Abstract
Purpose – This paper aims to create a model for evaluating organizational change initiatives from a
stakeholder resistance viewpoint.
Design/methodology/approach – The paper presents a model to evaluate change projects and
their expected benefits. Factors affecting the challenge to implement change were defined based on
stakeholder theory literature. The authors test the model’s practical validity for screening change
initiatives to improve operating room productivity.
Findings – Change initiatives can be evaluated using six factors: the effect of the planned
intervention on stakeholders’ actions and position; stakeholders’ capability to influence the project’s
implementation; motivation to participate; capability to change; change complexity; and management
capability.
Research limitations/implications – The presented model’s generalizability should be explored
by filtering presented factors through a larger number of historical cases operating in different
healthcare contexts. The link between stakeholders, the change challenge and the outcomes of change
projects needs to be empirically tested.
Practical implications – The proposed model can be used to prioritize change projects, manage
stakeholder resistance and establish a better organizational and professional competence for
managing healthcare organization change projects.
Originality/value – New insights into existing stakeholder-related understanding of change project
successes are provided.
Keywords Stakeholder analysis, Organizational change, Project management, Operating theatres,
Finland
Paper type Conceptual paper

Introduction
International Journal of Health Care Change management is a one of the key tasks for any manager. However, changing an
Quality Assurance organization is difficult and it is estimated that about 70 percent of all initiatives fail
Vol. 21 No. 5, 2008
pp. 418-434 (Beer and Nohria, 2000; Higgs and Rowland, 2000). A deep transition, which necessitates
q Emerald Group Publishing Limited
0952-6862
changes in organizational culture, is even more challenging. Published estimates for
DOI 10.1108/09526860810890413 success in culture changes range from 10 to 32 percent (Smith, 2003). Poor management
during implementation is a common cause of failure, but another reason for low success Organizational
rates may be that in the project selection phase, stakeholder participation and support is change projects
not secured (Trader-Leigh, 2002). Our objective, therefore, is to provide a rational and
practical approach for managers involved in change management. We propose that the
likelihood of change project success can be improved through:
.
detailed organizational performance analysis;
.
identifying alternative solutions for improving performance;
419
.
project complexity assessment;
.
understanding stakeholder resistance towards alternative solutions; and
.
carefully selecting the most promising change project initiatives for
implementation.

These steps ensure that both expected benefits and the risks of not achieving those
benefits owing to organizational resistance are taken into account in the project selection
process. Additionally, organizational resistance toward change project can also be used
to assign resources and manage change during the implementation phase. We have
selected stakeholder approach as a theoretical background and we apply it in the context
of organizational change. As managers continuously make investment decisions in the
context of competing changes, we introduce a model to assess and compare
organizational change initiatives. The model is applied in a healthcare setting to facilitate
the analysis of change initiatives for improving operative performance. Finally, we
discuss the managerial practicality of the model and avenues for further research.

Applying stakeholder theory to change projects

Freeman’s (1984) stakeholder theory has been applied to various areas such as
corporate responsibility (Buchholz and Rosenthal, 2004), business ethics and project
management (Turner and Simister, 2000). It has also been used in the context of
organizational change (Trader-Leigh, 2002) and in combination with governance
theories of economic organizations such as agency theory, transaction cost economics
and property rights theory (Parvinen et al., 2005). We propose that stakeholder theory
provides an interesting perspective in the management of organizational change
projects, because organizational change is dependent on the resources possessed by
various stakeholder groups and the support of key stakeholders. The focus of our
research, therefore, is on a project’s early phases when choosing the most appropriate
topics amongst multiple change initiatives.
In accordance with Freeman’s (1984, p. 46) classical stakeholder definition we define
a change project stakeholder as “any group or individual who can affect or is affected
by the implementation of the change project”. Stakeholders also hold a central role in
project management. According to the PMBOK Guide (2005, p. 24), project
management includes adopting specifications, plans and approaches to different
stakeholders’ concerns and expectations. Balancing stakeholder expectations has a
direct influence on how they are motivated to support proposed change. These
concerns must be addressed in the project selection process because they are important
when evaluating stakeholder resistance to change. Mitchell et al. (1997) provide a
comprehensive model for evaluating the salience of various stakeholder groups; i.e.
their influence in managerial decision-making processes. Frooman (1999), drawing
IJHCQA from resource dependence theory, evaluates different strategies used by stakeholders
21,5 who possess resources critical to the firm gaining control over the organization. He
proposes that an important aspect to consider is whether the firm and stakeholders are
mutually dependent on each other.

420 Evaluating organizational change initiatives

Few models exist for predicting organizational change outcomes (Olsson et al., 2003;
Gustafson et al., 2003). These models specify utilization factors that are important for
successful improvement. However, they do not provide an integrated framework for
project selection, which takes into account benefits, costs and the probability of a
change project’s success. We propose that selecting organizational change projects
should be based on two factors: the project’s expected benefits in the context of
organizational goals; and how challenging the implementation of the project is.
Implementation challenges can be determined by assessing the change project’s
complexity and resistance among participants. In Figure 1, four different types of
organizational change projects are identified based on these two dimensions:
(1) Low hanging fruits are changes that lead to assured results with only minor
effort. These changes can be implemented as soon as the need for them becomes
apparent and are common in situations where there has not been any concrete
intention to develop the organization earlier.
(2) Continuous improvement means an ongoing series of minor interventions,
which creates steady, but marginal, growth (Imai, 1986).
(3) Contrary to continuous improvement, strategic development projects require
the managers’ attention. The project’s expected results are breakthrough
improvements, such as cost structure or competitiveness (Johnston et al., 2001).
(4) Lemons are projects when assessed in detail prove to be impossible or too labor
intensive to implement for the expected results, and thus must be dismissed.
Implementing them can diminish managers’ credibility and legitimacy. An
example of a lemon is an IT system that does not fulfill its reliability
requirements and causes needless expenses and personnel orientation costs.

Figure 1.
A model to assess projects
Implementing selected projects should be started from “low hanging fruits” since they Organizational
lead to immediate benefits. After these relatively easy changes, managers have to change projects
create a constant system for achieving continuous improvement and ultimately,
managers needs to prepare for selection and implementation of strategic development
projects. Selecting appropriate projects as well as timing and adequately resourcing
them require the systematic evaluation of change initiatives along the two dimensions
seen in Figure 1. 421
Assessing expected benefits
We focus mainly on the impact of change initiatives on profitability and cost-efficiency.
A project’s expected benefits are usually calculated using capital investment appraisal.
Investment calculations, however, do not take into account the way change affects an
organization. The influence of these effects can be more specifically assessed using, for
example, the balanced scorecard (Kaplan and Norton, 1992), which takes into account
economic, internal process, customer and innovativeness considerations. In many
cases a simple method, such as productivity or market share growth, is sufficient to
determine a project’s benefits. It is essential that selected indicators reflect organization
goals and can be reliably calculated for different projects. Presenting expected benefits
numerically makes it easier to compare competing interventions. Legislative and
business circumstance changes might force an organization to implement change
projects regardless of expected financial benefits. The benefits or consequences of
these projects need to be assessed too because their identification advances effective
implementation. The financial effects of implementing strategic projects necessary for
the organization’s existence also need to be calculated and evaluated.

Assessing implementation challenges

The challenge of managing and implementing projects can be analyzed by applying
stakeholder and resistance theories (Freeman, 1984). Resistance toward change is
comprised of actions whose aim is to terminate intended organizational change (Lines,
2004). Estimating the challenge during project implementation is not as easy as
assessing the benefits of change, as the analysis must consider management goals as
well as the dispersed and even opposing stakeholder goals. We propose that challenges
can be estimated by taking into account stakeholders’ resistance toward the change, its
complexity of and managers’ capability. Further stakeholder theory analysis
(Trader-Leigh, 2002; Freeman, 1984; Mitchell et al., 1997) shows that the source of
resistance toward change can be divided into four factors:
(1) Planned intervention’s effect on stakeholders’ actions and position.
(2) Stakeholders’ capability to influence the project’s implementation, which
determines how much power they use to resist change.
(3) Goal clarity, which influences motivation to participate.
(4) Capability to change.

In the next section we present these four stakeholder specific factors and two general
factors affecting the level of challenge to change implementation:
(1) Change complexity.
(2) Managers’ capability.
IJHCQA The effect of the planned intervention on stakeholder action and position
21,5 According to Freeman (1984), a stakeholder can be defined as a group affected by
change. The intensity of stakeholder reaction to change initiatives is proportional to
the expected changes in their position and the extent to which the goals of the
intervention match stakeholder goals. Stakeholder motivation to participate in the
change or to hinder the implementation is greatly influenced by their assumptions
422 about the conceivable changes.

Stakeholder’s implementation influence

Stakeholders can influence the change process either by influencing managerial
decision-making or by not providing the necessary resources for the change. Mitchell
et al. (1997) provide a framework for analyzing stakeholders’ decision-making
influence, which depends on their power and legitimacy within the organization and
the urgency of their claims to the organization. Capability to influence defines the
salience of stakeholder from a managerial point-of-view. Resource dependence theory
suggests that power accrues to those stakeholders who control resources crucial to the
organization (Pfeffer, 1981). In the context of organizational change, we can assume
that those stakeholders who control critical and non-substitutable resources required
for the change have more power to influence both decision-making and
implementation.

Motivation to participate
Core stakeholder participation in organizational change projects is an essential success
factor (Salminen, 2000). Stakeholders’ capability to influence does not, however,
necessarily imply that they will actively attempt to use this influence to promote
change. Stakeholder actions are strongly affected by existing incentives to resist or
promote change (Trader-Leigh, 2002). If change is intended to be permanent then
stakeholder incentives have to be sufficient during the change process (Gibbons, 1998).
Understanding the current situation and having clearly defined goals (O’Toole, 1993)
are the minimum requirements for motivation to change. Participation is driven by
stakeholders’ assumed change benefits and costs and the perceived risk of not reaching
goals. The level of opportunism is defined as stakeholders’ attitudes and decisions
based mainly on sub-optimization or consideration of the overall benefits of the change.

Capability to change
Some initiatives require radical work practice changes when others might be executed
with only incremental alterations. New knowledge and skills are required to change an
organization. Dynamic capabilities are a set of specific processes that determine how
easy it is for an organization to reconfigure its resources in a changing environment
(Eisenhardt and Martin, 2000). Besides the lack of individual skills there are cultural
assumptions and normative rules in an organization. These are difficult to change and
might hinder the capability of various stakeholders to change their work practices
(Schein, 1992). In their research, Reger et al. (1994) focused on the cognitive sources of
human resistance and explained why even the most loyal members, who sincerely
want the best for the organization, are resistant to change.
Complexity of change Organizational
The need for integration and systematic project management is greatest when different change projects
parts of the organization are required to work together (Morris, 1994). The complexity
of change can be measured as the number of stakeholders involved and the required
interaction and co-ordination between them. If stakeholders increase then there are
more competing values and goals, which complicate the implementation. Many
organizational changes entail growing interaction between stakeholders. This might 423
require new information channels and informal networks and force stakeholders to
consider organization activities from a more comprehensive point-of-view.

Management capability
Management capability can be defined as how effectively and creatively managers use
and direct internal resources and capabilities to deal with its environment (Acquaah,
2003). Ensuring high management capability is especially essential when the project
aims to change prevailing organizational culture (Smith, 2003). Capability consists of
managers’ experience executing similar projects, their readiness to manage complicated
changes and stakeholder respect for and commitment to management. Managers’ power
defines the authority to implement changes. Stakeholder independence and propensity to
resist change restrict this power. We propose that the total challenge (TC) of
implementing a change project can be determined by inclusive analysis of these four
stakeholder-specific (A-D) and two general (E and F) resistance factors:
1X
TC ¼ ð Ai Bi þ C i þ Di Þ þ E þ F ð1Þ
i i

In equation (1) the score for individual stakeholder resistance (Ai Bi þ C i þ Di ) is

calculated. Factors A and B are multiplied, because the expected changes in
stakeholder position and action (A) determines how much a stakeholder is likely to use
their power (B) to resist the change. The average score for stakeholder resistance:
1X
ð Ai Bi þ C i þ Di Þ
i i

is calculated by adding individual scores and then dividing them by the number of
relevant stakeholders (i ). Finally, the general factors E and F are added to create a total
challenge (TC) to implement the change project.

Case: PHCH operating unit

Case introduction
Our assessment model’s validity was tested in Finland’s Päijät-Häme Central Hospital
(PHCH) operating unit serving 220,000 inhabitants. The operating unit was built in
1976 and includes 15 operating rooms (OR), 12 of which can be used for all types of
surgery. The PHCH operating unit covers 12 specialties, the busiest of which are
orthopedics, gynecology and gastroenterology. The total annual number of operations
was nearly 11,000 in the years 2002-2004; 23 percent of patients are acute and require
surgery close to admission. The staff in the operating unit consists of nine
anesthesiologists, 63 registered nurses and 14 other employees.
IJHCQA The assessment model we propose was tested in the context of PHCH’s development
21,5 work. In September 2004, PHCH managers initiated a project in which the ultimate
target was to decrease the cost of individual operating units and enhance the
availability of surgical care. They decided to identify the procedural inefficiencies and
bottlenecks by process analysis. The salient goal was to increase OR productivity
defined as total patient in OR time divided by total personnel hours for a given period
424 of time. Operating room management (ORM) is an independent and established area of
scientific research. There is an existing body of research devoted to resource allocation
between specialties and units (Schultz and Melson, 1990; Dexter et al., 1999; Warnock,
2004). The trend has been to move toward a more dynamic OR allocation to specialties
and balancing supply with predicted demand for operations (Dexter et al., 1999; Dexter
and Macario, 2002). Much research has been done in the area of increasing resource
utilization and patient flow by moving care phases out of the OR (Sieber and
Leibundgut, 2002). Scheduling, for example determining the optimal sequence of
operations (Weiss, 1990) and management decisions on the day of surgery (Dexter et al.,
2004) have been developed to increase operating unit efficiency. The primary ORM
aspiration is to maximize resource utilization and overall productivity in the operating
unit. Improving utilization rates and especially personnel productivity were other
goals in PHCH’s development initiatives.

Entering the field

The present state analysis of processes involving surgical patients started with looking
at information from the hospital databases concerning care process from calling a
patient to the operating unit to the time of discharge from the recovery room. We
analyzed 10,802 surgical patients between September 2003 and August 2004, including
time, resource and location information about the various care phases and delays
between them. After the present-state analysis, PHCH managers formulated potential
process change initiatives – based on our assessment model. Expected productivity
changes derived from process analysis data and challenges to implementing a
particular intervention were calculated using equation (1). Numerical values for the six
resistance factors (from A to F) were determined based on structured interviews
carried out by two external researchers familiar with the case. The researchers
interviewed one person from each relevant stakeholder group. The most relevant
stakeholder groups were identified with managers’ help as a part of the present-state
analysis.
The eight selected groups were:
(1) Operating room team nurses.
(2) Recovery room nurses.
(3) Ward nurses.
(4) Surgeons.
(5) Anesthesiologists.
(6) Specialty heads.
(7) Operative managers.
(8) Practical nurses’ trade union.
These stakeholders were selected because they were the most involved in changes or Organizational
were judged to wield significant power to influence project implementation. change projects
Interviewees were selected randomly among persons who had over five years
experience in a current stakeholder group. Previous research has shown that resistance
to change is often deliberately hidden (Fleming and Sewell, 2002); we did not ask
directly about resistance but about factors that contribute. To increase the reliability of
our results, we used semi-structured interviews that enabled researchers to analyze if 425
there were any hidden agendas. During interviews stakeholders were first asked about
their perceptions of different resistance factors (see the Appendix). After that,
interviewees were asked about their opinions about stakeholder power and motivation.
Based on interviewees’ answers, researchers defined a numerical value for each of the
six factors using a scale from 0 to 5. For factors A to D the numerical values were
defined stakeholder-specific and for complexity of the change (E) and management
capability (F) the values were defined project-specific. Using this scale scores from 0 to
45 (equation 1) were obtained.

Results
The surgical patient PHCH process analysis exposed remarkably low OR and surgeon
utilization rates. On average, the OR utilization during office hours was only 57 percent
and the highest rate of single OR utilization was just 73 percent. The average surgeon
utilization rate (office hours active surgery time) was, at best, under 40 percent. Some
OR time was wasted in the morning before the start of the first surgery, between
surgeries and in the evening before the end of office hours. One quarter of the morning
patients were admitted to the OR more than 30 minutes late. The average
non-operative time (time from closure to the next incision) was 71 minutes, and in
orthopedic ORs more than 100 minutes. The time of the last operation in the day
varied: on average there was overtime work in 30 percent of ORs, but at the same time,
an average of 105 idle minutes occurred in 30 percent of the ORs. Inside the OR,
anesthesiologists delayed the process on average by 7.6 minutes and surgeons delayed
the process by 4.5 minutes. In the next section we illustrate four projects, their expected
influence on OR personnel productivity and the challenges’ numerical value of
implementing the projects derived from stakeholder interviews.

Moving the induction of anesthesia outside the OR

Presently, patient anesthesia preparation takes 28 percent of OR turnover time.
However, some preparation phases (e.g. local anesthesia) can be moved outside the OR
and performed safely in existing induction rooms or recovery rooms. By allocating one
nurse and 0.25 anesthesiologists more to one OR, preparing the next patient can be
performed during the present operation. As a result of growing surgeon utilization rate
and patient flow per OR, the productivity of personnel increases 8 percent using
induction and 4 percent in the whole operating unit if induction is used in half of the
ORs. Based on our interviews, surgeons and operative managers are content with the
expected effect of this change (Table I). Anesthesiologists and nurses are somewhat
doubtful about the change’s usefulness and feasibility. However, their professional
competence to perform anesthesia induction outside the OR is sufficient.
IJHCQA
Recovery
21,5 Induction of anesthesia outside the Team room Operative
operating room (i ¼ 5) nurses nurses Anesthesiologists Surgeons management

(A) Influence of intervention on

stakeholder 3 3 3 0 1
426 (B) Capability to influence on
implementation 3 3 4 0 2
(C) Motivation to participate 4 3 3 1 1
(D) Capability to change 3 2 2 0 1
Individual stakeholder resistance
(Ai Bi þ C i þ Di ) 16 14 17 1 4
Average
P stakeholder resistance
1=i ðAi Bi þ C i þ Di Þ 1=5ð16 þ 14 þ 17 þ 1 þ 4Þ ¼ 10:4
Table I. (E) Complexity of change 3
Challenge to implement (F) Management capability
P 1
the induction of Total challenge 1=i ðAi Bi þ C i þ
anesthesia outside the OR Di Þ þ E þ F 14.4

Process interface guidance

Operating room time is wasted because a patient or a clinician is called too late. By
forecasting forthcoming events and calling the patient and clinician at the optimal time
the average OR turnover time can easily be shortened by ten minutes, which translates
to a 5 percent productivity improvement. This also requires commitment to
punctuality from surgeons, anesthesiologists and ward units. Delay monitoring in the
process interfaces makes it possible to identify problems and compare clinicians and
units. According to stakeholders’ opinions, the biggest challenge is minimizing the
delay before notifying the anesthesiologist and to motivate nurses to call patients and
clinicians early enough (Table II). Owing to reduced waiting time and better
anticipation of forthcoming events, stakeholders consider this change mainly positive.

Developing processes at the start of the day

Idle time before the first patient is admitted in the morning is a main problem in most
ORs. The focus of control should be moved from patient admission to the start of
surgery, which motivates nurses and anesthesiologists to make mornings more

Team Ward
Guidance in process interfaces (i ¼ 4) nurses Anesthesiologists Surgeons nurses

(A) Influence of intervention on stakeholder 3 2 2 1

(B) Capability to influence on implementation 5 2 2 0
(C) Motivation to participate 3 2 2 1
(D) Capability to change 3 2 2 1
Individual stakeholder resistance (Ai Bi þ C i þ Di ) 21 8 8 2
Table II. Average
P stakeholder resistance
Challenge to 1=i ðAi Bi þ C i þ Di Þ 1/4(21 þ 8 þ 8 þ 2) ¼ 9.8
implementing process (E) Complexity of change 1
interface guidance (F) Management capability
P 2
Total challenge 1=i ðAi Bi þ C i þ Di Þ þ E þ F 12.8
effective. For example, nurses and anesthesiologists could schedule the first patient’s Organizational
preparation in advance, which tells the ward staff and surgeon about the planned time change projects
of patient admission and start of surgery, respectively. Two ORs, both with long
anesthesia preparation in the morning, should not be assigned to any anesthesiologists.
In the case of two concurrent preparations, the anesthesiologist should start with the
patient needing shorter preparation. By advancing the surgery start time by 20
minutes, productivity increases by 5 percent. However, many anesthesiologists and 427
nurses (Table III) were unconvinced by the change’s usefulness, but many were content
with their increased responsibilities.

Elective operation contract policy

Elective and emergency surgery in the same OR shift diminishes incentives. As OR
processes stand we believe that the probability of getting emergency cases after the
elective surgery list is complete is low, which does not encourage efficiency.
Emergency and elective operations, therefore, should be assigned to their own OR
teams. The allocation of elective ORs to specialties has to be adjusted four weeks
beforehand according to demand. Four weeks, however, is time enough for scheduling
OR days and informing patients. In elective ORs, efficiency can be improved by
implementing a contract policy by which cases are allocated to teams two weeks in
advance. Typically, OR schedules are based on historical operation completion and
turnover times. However, more flexible working hours are needed. Operating unit
personnel should be rewarded for increased efficiency with money and free time.
Implementing a contract policy for elective operations improves OR utilization and
minimizes delays in all process phases, which we estimate increases productivity by at
least 15 percent. According to our interviews contract policy is driven mainly by
operative management (Table IV). The resistance of some nurses and anesthesiologists
and especially the trade unions makes change implementation challenging.

Discussion
Managers’ capability was estimated to be relatively low in all change initiatives owing
to a lack of experience and previous poor project results. Many stakeholders argued
that problems were identified with moderate accuracy before our study, but managers
had no desire to change the situation. Change projects are allocated to the assessment

Team Ward
Developing start of the day (i ¼ 4) nurses Anesthesiologists Surgeons nurses

(A) Influence of intervention on stakeholder 4 3 1 1

(B) Capability to influence on implementation 5 5 2 2
(C) Motivation to participate 3 3 2 2
(D) Capability to change 3 3 1 2
Individual stakeholder resistance (Ai Bi þ C i þ Di ) 26 21 5 6
Average
P stakeholder resistance Table III.
1=i ðAi Bi þ C i þ Di Þ 1=4ð26 þ 21 þ 5 þ 6Þ ¼ 14:5 Challenge to
(E) Complexity of change 4 implementing start of the
(F) Management capability
P 2 day developments
Total challenge 1=i ðAi Bi þ C i þ Di Þ þ E þ F 20.5
IJHCQA
Contract policy for elective Team Operative Head of Trade
21,5 operations (i ¼ 6) nurses Anesthesiologists Surgeons management specialty union

(A) Influence of intervention

on stakeholder 3 3 3 0 3 4
(B) Capability to influence on
428 implementation 4 4 4 5 2 3
(C) Motivation to participate 3 2 1 1 2 4
(D) Capability to change 4 3 2 1 3 5
Individual stakeholder
resistance (Ai Bi þ C i þ Di ) 19 17 15 2 11 21
Average
P stakeholder resistance
Table IV. 1=i ðAi Bi þ C i þ Di Þ 1=6ð19 þ 17 þ 15 þ 2 þ 11 þ 21Þ ¼ 14:2
Challenge to (E) Complexity of change 5
implementing the elective (F) Management capability
P 4
operations’ contract Total challenge 1=i ðAi Bi þ
policy C i þ Di Þ þ E þ F 23.2

model (Figure 2) based on their estimated benefit implementation challenges

(Tables I-IV). The model suggests that:
.
Induction outside the OR (1) and guidance in the process interfaces (2) are easily
implemented (3).
.
Developing processes at the start of the day is close to being a lemon as it is
challenging to implement and provides minor benefits.
.
The biggest influence on productivity can be achieved by (4) moving toward a
contract policy – also the most challenging project to implement.

Our analysis shows that the first project to implement should be project (2): guidance in
process interfaces. After that staff should strive to improve (1) induction outside the
OR. Project (4), moving toward a contract policy, is attractive from a managerial point
of view, but it may be necessary to implement minor changes first and to plan and
manage them carefully on a strategic level later. Project (3), developing the start of the
day processes, could also be implemented, but managers have to ensure that failure in

Figure 2.
Identified four PHCH
projects in assessment
model
its implementation would not have a negative effect on other change projects. Our Organizational
surgical care processes’ analysis exposed potential for increasing OR productivity. The
main reasons for delays and inefficiencies were unsystematic acute-patient
change projects
management, lack of incentives and insufficiently developed scheduling practices. A
common observation from the interventions we analyzed was that the largest
resistance toward change derives from operative personnel - particularly nurses and
anesthesiologists. Motivating these groups seems to be critical for managing operating 429
unit change. Further study, therefore, should be focused on discovering why nurses
and anesthesiologists were the most reluctant to change. We hypothesize that the
reason for most delays and process inefficiencies lies in stagnant culture and lack of
incentive systems. We recommend, therefore, that PHCH managers create an
innovative environment for improving their operating units.
Conclusions and research implications
We assumed a highly rationalistic approach to change with the intention of exploring
the boundaries of managerial discretion. Our aim was to present a radical alternative to
the managerialist perspectives to healthcare management that emphasize relativity,
subjectivism and cognitions. While realizing that our approach does not capture
“reality” in an encompassing way, we propose that this exercise can demonstrate the
breadth of alternatives available to management for analyzing stakeholder settings.
Furthermore, the approach is geared to stir discussion. Another aim was to present a
practical managerial framework for assessing and selecting change projects.
Factors presented in the context of the framework were based on stakeholder
theory. Our article is not based on change management literature but it provides a
simplified model for managing organizational change. As such it does not take into
account the full complexity of organizational change (see, e.g. Sturdy and Grey, 2003).
For example, routine workplace resistance implications (Prasad and Prasad, 2000) are
not discussed. Rather, we provide an explanatory mechanism for failure in
organizational transition from stakeholder theory perspective (Knox and Irving,
1997; Cule and Robey, 2004; Amis et al., 2004). In doing so, we contribute to existing
stakeholder-related understanding change project success (Trader-Leigh, 2002).
Stakeholder management is said to be common sense or intuitively obvious.
However, in organizational contexts, where stakeholders are active, knowledgeable
and interdependent, success is dependent on active, practical stakeholder relationship
management (Savage et al., 1991). This is particularly true in healthcare contexts
(Fottler et al., 1989; Savage et al., 1997). Consequently, we provide an avenue for
introducing this logic into the analysis of healthcare change projects. In the future,
stakeholder research in healthcare will need to move beyond the simplistic but
conventional idea that stakeholders matter in determining change success outcomes.
The types of stakeholder networks and their influence on the change process needs to
be elaborated in more normative detail. Research will have to filter the tentative ideas
we present into concrete, testable hypotheses and propositions. Empirical research is
first needed to crystallize the logic of the argument. Generalizability could be explored
by filtering the presented factors through a larger number of historical cases operating
in different healthcare contexts. Second, the link between stakeholders, the total change
challenge and the outcomes of change projects needs to be empirically tested. For this
purpose, partitioning outcomes to change realization, change durability and
organizational success through change is necessary. This allows a testable research
IJHCQA setting to investigate the correlations between individual factors in the assessment
21,5 phase and project success.
Pursuing change and transforming organizations is hard work. Many change
initiatives fail because their selection is based on deficient stakeholder resistance
analysis. During the change process, the existing resistance might surprise managers
or the expected benefits of the project may prove to have been overestimated. The
430 proposed model for assessing change projects aids the rough classification of
initiatives and provides a tool for establishing a foresight into the challenge of change
implementation. Accurately evaluating challenges when implementing a project is
difficult, but the model brings up factors affecting the feasibility of change. The first
managerial implication is that total stakeholder challenge analysis can be used to
assess the organizational context. The proposed model can be used for change project
portfolio management, essentially selecting and prioritizing change projects within the
organization by comparing one project to another. Project selection should be based on
two variables: expected benefits and the challenge implementing the change. After
these are considered, managers can concentrate on guiding the organization in the
chosen direction. Our model is useful for understanding, selecting and managing
change projects in complex healthcare contexts. It is particularly, useful in contexts
characterized by numerous independent professional groups with differing targets and
incentives. In these settings, the challenge often consists of anticipating, preventing
and curbing opportunistic “partial optimization” behavior by the different
stakeholders.
We produce a tentative, prescriptive process model for change project management.
A comprehensive collection of factors affecting the challenge of implementing the
project should be determined for different organizations and stages in change process.
What variables affect the success of implementation at different change process phases
and what special characteristics of variables in different organizations are important
questions. We propose that managers should use the following six-step process for
selecting change projects:
(1) Set clear goals for organizational change (e.g. costs reduction, productivity
improvement).
(2) Identify potential change projects and analyze how they contribute to
organizational goal achievement.
(3) Identify stakeholder groups influenced by, or having influence on, change
projects.
(4) Analyze stakeholder resistance, the complexity of the change and management
capability by interviewing stakeholder group representatives (equation 1).
(5) Categorize and select change projects to be implemented (Figure 1).
(6) Create a plan and assign adequate resources for project implementation, taking
into account stakeholder resistance and the complexity of the change.

Even if there is no case for project selection in organization, introducing stakeholder

analysis is a worthwhile project. This system, used to identify resistance and attitudes
before implementation, can greatly enhance acceptance of change initiatives.
Evaluation before implementation makes it possible to modify the change and
motivate the salient stakeholders in order to ensure its success. This understanding is
particularly useful for crafting change project management details with different Organizational
governance practices (e.g. incentive schemes, information sharing, employee change projects
monitoring, designing power and authority, process ownership or even outsourcing).
Within larger healthcare organizations, our model can also be used for risk
management and quantifying the financial risks related to the change projects. Risk
assessments frequently fail to produce any tangible measure for the risk associated
with change management. The total challenge score could be used to establish this 431
missing link. Finally, systematic treatment of the challenge facilitates a structured
discussion among stakeholders about the realism of change initiatives. Exposing the
change challenge assessment to debate among the personnel is a feasible way of
removing hidden agendas, exposing the threats of failure and reaching a uniform
understanding of the change management task among employees. Post-mortems of
past change management initiatives can be used to educate managers and
professionals, and the proposed approach provides a useful backbone for such
sessions. Generally, the model can thus be used to establish better managerial and
organizational competence for change project management.

References
Acquaah, M. (2003), “Corporate management, industry competition and the sustainability of firm
abnormal profitability”, Journal of Management and Governance, Vol. 7 No. 1, pp. 57-85.
Amis, J., Slack, T. and Hinings, C.R. (2004), “The pace, sequence and linearity of radical change”,
Academy of Management Journal, Vol. 47 No. 1, pp. 15-39.
Beer, M. and Nohria, N. (2000), “Cracking the code of change”, Harvard Business Review, Vol. 78
No. 3, pp. 133-41.
Buchholz, R. and Rosenthal, S. (2004), “Stakeholder theory and public policy: how governments
matter”, Journal of Business Ethics, Vol. 51 No. 2, pp. 143-53.
Cule, P. and Robey, D. (2004), “A dual-motor, constructive process model of organizational
transition”, Organization Studies, Vol. 25 No. 2, pp. 229-60.
Dexter, F. and Macario, A. (2002), “Changing allocations of operating room time from a system
based on historical utilization to one where the aim is to schedule as many surgical cases
as possible”, Anesth Analg, Vol. 94, pp. 1272-9.
Dexter, F., Macario, A., Qian, F. and Traub, R.D. (1999), “Forecasting surgical groups’ total hours
of elective cases for allocation of block time”, Anesthesiology, Vol. 91 No. 5, pp. 1501-8.
Dexter, F., Epstein, R.H., Traub, R.D. and Xiao, Y. (2004), “Making management decisions on the
day of surgery based on operating room efficiency and patient waiting times”,
Anesthesiology, Vol. 101 No. 6, pp. 1444-53.
Eisenhardt, K. and Martin, J. (2000), “Dynamic capabilities: what are they?”, Strategic
Management Journal, Vol. 21 Nos 10/11, pp. 1105-21.
Fleming, P. and Sewell, G. (2002), “Looking for the good soldier, Švejk: alternative modalities of
resistance in the contemporary workplace”, Sociology, Vol. 36 No. 4, pp. 857-73.
Fottler, M., Blair, J., Whitehead, C., Laus, M. and Savage, G. (1989), “Assessing key stakeholders:
Who matters to hospitals and why?”, Hospitals and Health Services Administration, Vol. 34
No. 4, pp. 525-46.
Freeman, R.E. (1984), Strategic Management: A Stakeholder Approach, Pitman, Boston, MA.
Frooman, J. (1999), “Stakeholder influence strategies”, Academy of Management Review, Vol. 24
No. 2, pp. 191-205.
IJHCQA Gibbons, R. (1998), “Incentives in organizations”, The Journal of Economic Perspectives, Vol. 12
No. 4, pp. 115-32.
21,5
Gustafson, D., Sainfort, F., Eichler, M., Adams, L., Bisognano, M. and Steudel, H. (2003),
“Developing and testing a model to predict outcomes of organizational change”, Health
Services Research, Vol. 38 No. 2, pp. 751-76.
Higgs, M. and Rowland, D. (2000), “Building change leadership capability: ‘the quest for change
432 competence’”, Journal of Change Management, Vol. 1 No. 2, pp. 116-31.
Imai, M. (1986), Kaizen: The Key to Japan’s Competitive Success, Long River, Taipei.
Johnston, R., Fitzgerald, L., Markou, E. and Brignall, S. (2001), “Target setting for evolutionary
and revolutionary process change”, International Journal of Operations & Production
Management, Vol. 21 No. 11, pp. 1387-403.
Kaplan, R. and Norton, D. (1992), “The balanced scorecard – measures that drive performance”,
Harvard Business Review, Vol. 70 No. 1, pp. 71-9.
Knox, S. and Irving, J. (1997), “An interactive quality of work life model applied to organizational
transition”, Journal of Nursing Administration, Vol. 27 No. 1, pp. 39-47.
Lines, R. (2004), “Influence of participation in strategic change: resistance, organizational
commitment and change goal achievement”, Journal of Change Management, Vol. 4 No. 3,
pp. 193-215.
Mitchell, K., Agle, B. and Wood, D. (1997), “Toward a theory of stakeholder identification and
salience: defining the principle of who and what really counts”, Academy of Management
Review, Vol. 22 No. 4, pp. 853-86.
Morris, P. (1994), The Management of Projects, Thomas Telford, London.
O’Toole, L. (1993), “Interorganizational policy studies”, Journal of Public Administration
Research and Theory, Vol. 3 No. 2, pp. 232-51.
Olsson, J., Ovretveit, J. and Kammerlind, P. (2003), “Developing and testing a model to predict
outcomes of organizational change”, Quality Management in Health Care, Vol. 12 No. 4,
pp. 240-9.
PMBOK Guide (2005), Project Management Body of Knowledge, 3rd ed., Project Management
Institute, Newtown Square, PA.
Parvinen, P., Kujala, J., Lillrank, P. and Kouri, J. (2005), “Managing process interventions in
healthcare: a question of governance”, 4th International Conference on the Management of
Healthcare and Medical Technology, Aalborg, 25-26 August.
Pfeffer, J. (1981), Power in Organizations, Pittman, Marshfield, MA.
Prasad, P. and Prasad, A. (2000), “Stretching the iron cage: the constitution and implications of
routine workplace resistance”, Organization Science, Vol. 11 No. 4, pp. 387-403.
Reger, R., Gustafson, L., Demarie, S. and Mullane, J. (1994), “Reframing the organization: why
implementing total quality is easier said than done”, Academy of Management Review,
Vol. 19 No. 3, pp. 565-84.
Salminen, A. (2000), “Implementing organizational and operational change: critical success
factors of change management”, Acta Polytechnica Scandinavica, Industrial Management
and Business Administration Series No. 7, The Finnish Academy of Technology, Espoo.
Savage, G., Nix, T., Whitehead, C. and Blair, J. (1991), “Strategies for assessing and managing
stakeholders”, Academy of Management Executive, Vol. 5, pp. 61-75.
Savage, G., Taylor, R., Rotarius, T. and Buesseler, J. (1997), “Governance of integrated delivery
systems/networks: a stakeholder approach”, Health Care Management Review, Vol. 22
No. 1, pp. 7-20.
Schein, E.H. (1992), Organizational Culture and Leadership, 2nd ed., Jossey-Bass, San Francisco, Organizational
CA.
change projects
Schultz, M. and Melson, L. (1990), “Teamwork leads to better operating room management”,
Healthcare Financial Management, Vol. 44 No. 1, pp. 32-7.
Sieber, T. and Leibundgut, D. (2002), “Operating room management and strategies in
Switzerland: results of a survey”, European Journal of Anaesthesiology, Vol. 19, pp. 415-23.
Smith, M. (2003), “Changing an organisation’s culture: correlates of success and failure”, 433
Leadership & Organization Development Journal, Vol. 24 Nos 5/6, pp. 249-61.
Sturdy, A. and Grey, C. (2003), “Beneath and beyond organizational change management:
exploring alternatives”, Organization, Vol. 10 No. 4, pp. 651-62.
Trader-Leigh, K. (2002), “Case study: identifying resistance in managing change”, Journal of
Organizational Change Management, Vol. 15 No. 2, pp. 138-55.
Turner, J. and Simister, S. (Eds) (2000), Gower Handbook of Project Management, Gower,
Aldershot.
Warnock, G. (2004), “Resource allocation in surgical departments”, Canadian Journal of Surgery,
Vol. 47 No. 1, pp. 5-6.
Weiss, E. (1990), “Models for determining estimated start times and case orderings in hospital
operating rooms”, IIE Transactions, Vol. 22 No. 2, pp. 143-50.

Appendix. Stakeholder interviews

Four change initiatives have been initiated in the PHCH operating unit development project.
These initiatives have been assessed to have a positive effect on the productivity of the unit.
Stakeholder interviews are utilized in estimating the feasibility of projects and the challenges
faced in their implementation. It is essential that interviewees are honest in explaining their
views and opinions. The management of the hospital will select the best projects for
implementation based on the expected benefits from, and resistance to, projects and the attitudes
that emerge from the interviews. Other projects will be modified or rejected based on the same
criteria.
The four identified change projects are:
(1) Moving the induction of anesthesia outside the OR.
(2) Guidance in process interfaces.
(3) Developing processes at the start of the day.
(4) Contract policy for elective operations.

The feasibility and challenge of implementing the projects are assessed through the next semi
structured questions for representatives of all stakeholder groups relevant for the change:
Stakeholder group?
A: Influence of intervention on stakeholder’s actions and position
– How will the change affect to the stakeholder’s position and action?
(0 ¼ no negative influence, 5 ¼ strong negative influence)
B: Stakeholder’s capability to influence on implementation
– How the stakeholder can affect on implementation of the project?
(0 ¼ no power, 5 ¼ strong stakeholder)
C: Motivation to participate
IJHCQA – How motivated the stakeholder group is to participate in change?
(0 ¼ very motivated, 5 ¼ no motivated)
21,5
D: Capability to change
– What does the change require of stakeholders?
(0 ¼ stakeholder is very capable to change, 5 ¼ no capable to change)
434 E: Complexity of change
– How complex you see the implementation from the whole organization point of view?
(0 ¼ simple, 5 ¼ very complex)
F: Management capability
– How capable is the management in implementing and managing the change?
(0 ¼ very capable, 5 ¼ no capable)
– What are the salient stakeholders of the change project?
a. What is your conception of salient stakeholders’ power to influence on
implementation?
b. What is your conception of salient stakeholders’ motivation to participate?

Corresponding author
Antti Peltokorpi can be contacted at: antti.peltokorpi@tkk.fi

To purchase reprints of this article please e-mail: reprints@emeraldinsight.com

Or visit our web site for further details: www.emeraldinsight.com/reprints