One quality improvement project undertaken in the High Tide Health System (HTHS) was led by Sylvia O. In this project, Sylvia sought to reduce the number of missed appointments at the ambulatory care clinic of HTHS. Changes of this nature come with various challenges. Different scholars have sought to characterize and model organizational changes, with Sylvia’s QI project being an excellent example of such a change. The original and foundational model of change was developed by Kurt Lewin in 1951 (Cummings, Bridgman, & Brown, 2015).

According to Lewin, organizational change happens in three stages: unfreezing, movement, and refreezing (Hussain et al., 2018). In the unfreezing stage, the organizational “status quo” is broken down in order to prepare everyone that change is necessary (Mind Tools, n.d.). During unfreezing, assumptions about “the way things are done” must be challenged, as well as any associated organizational culture and values (Mind Tools, n.d.). This stage is often very uncomfortable for the individuals within the organization (Mind Tools, n.d.). Next comes the movement stage—change is made during this part of the model (Hussain et al., 2018). The final stage is refreezing, during which time the organization becomes used to doing things in the new way, and a new sense of stability and comfort is created (Mind Tools, n.d.).

When considering Sylvia’s project, the unfreezing process would likely start with convincing HTHS leadership that change is necessary. This could involve showing managers and other leaders the numbers associated with lost revenue from missed appointments, compared to the cost of implementing her change. Once Sylvia got permission from HTHS leaders, she would then have to manage the unfreezing process on the ambulatory care clinic. This would involve excellent communication with the clinic staff, and thorough education about how the change fits into the goals of the clinic, the broader organization, and nursing ethics. For example, staff should be educated about how this will save the clinic money (which could then be used for other things that staff would like to see), and also how reducing missed appointments helps promote patient health and safety. Staff should also receive ample training so that they feel prepared to perform their job while meeting any new expectations. Project leaders should ensure they create a safe space and genuinely listen to any staff concerns. Not only will this ease any tensions or discomfort that the unfreezing process naturally brings, but this open communication could lead to helpful insights that improve the project.

During the movement stage, more training and education should occur. Leadership should rely on positive reinforcement when staff incorporate the changes into their practice. Leaders on the unit must also lead by example. Staff needs at this stage should be addressed. Patients should also be informed of the changes made, with verbal and written materials to help acclimate them to the shift in policy.

Lastly, the refreezing process will help solidify Sylvia’s change as a permanent part of the culture on the ambulatory care clinic. More positive reinforcement should be used! For example, leaders could come around at random, unannounced times; if they see a staff member using new expectations in their practice, they could be given a gift card or another reward.

There are many stakeholders involved in Sylvia’s QI project.  Some examples include Sylvia herself, HTHS leaders and executives, the managers and nurse educators on the ambulatory care clinic, clinic staff such as nurses and secretaries, and the clinic patients.




Cummings, S., Bridgman, T., & Brown, K. (2015). Unfreezing changes as three steps: rethinking Kurt

Lewin’s legacy for change management. Human Relations, 69(1), 33-60. https://doi-

Hussain, S., Lei, S., Akram, T., Haider, M., Hussain, S., & Ali, M. (2018). Kurt Lewin’s change

model: a critical review of the role of leadership and employee involvement in

organizational change. Journal of Innovation and Knowledge, 3(3), 123-127.

Mind Tools. (n.d.) Lewin’s change management model.