Contributor: Hephzibah Thomas

Kurt Lewin’s Change Theory provides a structured approach to understanding change at the group, organizational, and societal level (Burnes, 2004). Despite its age, this theory remains highly relevant for modern healthcare quality improvement initiatives due to its focus on both systems and human behavior change. Lewin conceptualized change as occurring through three distinct stages: unfreezing, change, and refreezing.

Quality Improvement project- The Clock Matters Unfreezing phase in the project

From September to November, 2024, the team collected baseline data on patient wait times, which revealed that only 61% of patient visits were starting within 15 minutes of room readiness. This quantitative evidence served as a powerful disconfirmation of the status quo. The team’s root cause analysis using a fishbone diagram helped shift focus from individual blame to systemic process issues, creating psychological safety for providers and staff to engage in the change process. By highlighting the serious consequences of delays, including cascading bottlenecks, staff stress, patient frustration, patients leaving without being seen, increasing complaints requiring manager intervention, deteriorating satisfaction scores, and potential risks due to interrupted care continuity, the team effectively established a compelling case for change that aligns precisely with Lewin’s concept of unfreezing.

Change Phase in the Project

The project’s implementation phase closely mirrors Lewin’s change stage. The team implemented several interventions that align with this theoretical stage: redefining the provider notification system expectation (shifting from a reactive to proactive approach), developing a formal Standardized Operating Procedure (SOP) for timely scheduled visits (providing clear guidelines), and establishing the 15-minute response expectation as a measurable standard (creating a specific target). The team’s monitoring of performance over a four-week period, which confirmed improvement from 61% to 95% of visits starting within 15 minutes, reflects the change aspect of Lewin’s change phase.

Refreezing Phase in the Project

The team established the 15-minute response expectation as a standard operating procedure, creating a sustainable culture of timeliness. Ongoing monitoring and feedback reinforced the new behaviors and prevented regression to previous practices. The team’s plan to expand the successful interventions to other clinic areas within the healthcare system represents the broader institutionalization described in Lewin’s refreezing phase.

Although the theory was not applied during implementation of the project, the retrospective analysis highlights the importance of incorporating theoretical frameworks in future healthcare quality improvement initiatives. This also suggests that explicitly using theory in future projects could enhance outcomes even further. Theories provide conceptual frameworks that help us understand, explain, and predict phenomena in systematic ways (McEwen & Wills, 2023). Despite benefits of theory application, many healthcare quality improvement initiatives proceed without explicit theoretical grounding, potentially limiting their effectiveness and sustainability (Nilsen, 2015). Although the “Clock Matters” project did not explicitly apply a theoretical framework, it successfully improved both operational efficiency and patient experience in a manner that closely aligns with Lewin’s unfreezing-change-refreezing model. Healthcare leaders seeking to implement sustainable change would benefit from intentionally grounding their improvement efforts in established theoretical frameworks from the outset. By consciously integrating theory and practice, future quality improvement initiatives can build on the intuitive success to achieve even more effective, comprehensive, and lasting results for the betterment of patient care

From Quick Fixes to a Sustainable Change

What if I told you that the difference between a quality improvement projects that works for few months versus one that transforms culture permanently isn’t about data or the process, it is about understanding the psychology of change? Our project “The Clock Matters” illustrates this point. We improved provider timeliness from 61% to 95% in just four weeks. Impressive, right? But when I analyzed our project through Meleis’ Transitions Theory, I realized that now we have an opportunity to create even deeper change. In today’s rapidly evolving healthcare, quality improvement initiatives are essential for enhancing patient care, streamlining operations, and improving outcomes.

Meleis’ Transition Theory

Transition Theory, developed by nursing theorist Afaf Meleis provides a comprehensive framework for understanding how individuals navigate change. Change is an external event whereas transition is an internal process (Smith, 2020). The theory conceptualizes transitions as a complex process that is influenced by multiple factors as seen in figure. Unlike more linear change models, this theory considers psychosocial dimensions of change, recognizing that organizational changes are ultimately experienced by individuals with unique perspectives, concerns, and adaptation capacities. In “the Clock Matters” project it is the nurses and other staff who were called upon to change how we manage timeliness. The theory explains how people experience and adapt to a change in their lives. These changes can happen one at a time, multiple, related to each other or separated. Transition conditions depend on personal, community and/or societal conditions. Success depends on the progress of how well people feel connected and confident during the process. The main insight is that all these elements work together in a cycle. The bidirectional relationship in the framework suggests that it provides a solid ground to move on to the next creating a positive loop that makes the transition more successful and sustainable while providing a robust model for scaling to other clinic areas.

Bridging Quality Improvement and Theory

Retrospectively analyzing this initiative through the lens of Transition Theory, we can highlight several advantages this theoretical framework offers for healthcare quality improvement. “The Clock Matters” project demonstrated that impressive results are just the beginning. When we achieved an improvement in the project, we just didn’t fix a scheduling problem; we created a transformative potential. While the project successfully addressed the organizational transition though system changes, incorporating the Transitions theory can provide a path for sustaining meaningful change . 

Imagine if every healthcare quality improvement initiative didn’t just change behaviors, but led to transformed identities. Envision projects that don’t just hit or exceed targets but create ripple effects of positive change throughout entire organizations. This is not a wishful thinking, this is the potential of integrating nursing theory with operational excellence. Theories provide conceptual frameworks that help us understand, explain, and predict phenomena in systematic ways (McEwen & Wills, 2023). Despite benefits of theory application, many healthcare quality improvement initiatives proceed without explicit theoretical grounding, potentially limiting their effectiveness and sustainability (Nilsen, 2015). Healthcare leaders seeking to implement sustainable change would benefit from intentionally grounding their improvement efforts in established theoretical frameworks from the outset. By consciously integrating theory and practice, future quality improvement initiatives can build on the intuitive success to achieve even more effective, comprehensive, and lasting results for the betterment of patient care. As this project expands to other clinic areas, incorporating aspects of Transitions Theory could enhance the adaptation process, potentially leading to even greater improvements in operational efficiency, staff engagement, and patient satisfaction in healthcare quality improvement, both the clock and human experience of change matters.

References

Burnes, B. (2004). Kurt Lewin and the planned approach to change: A re‐appraisal. Journal of Management Studies, 41(6), 977–1002. https://doi.org/10.1111/j.1467-6486.2004.00463.x

McEwen, M., & Wills, E. M. (2023). Theoretical basis for nursing (6th ed.). Wolters Kluwer.

Meleis, A. I. (2010). Transitions theory: Middle-range and situation-specific theories in nursing research and practice. Springer Publishing Company.

Nilsen, P. (2015). Making sense of implementation theories, models and Frameworks. Implementation Science, 10(1). https://doi.org/10.1186/s13012-015-0242-0

Smith, M. C. (2020). Nursing theories and nursing practice (2nd ed.). F A DAVIS.

About Hephzibah Thomas

As a healthcare professional and PhD nursing student at Texas Woman’s University with a focus on quality improvement and organizational change, my perspective is shaped by both clinical experience and academic inquiry. My analysis reflects a commitment to evidence-based practice, interdisciplinary collaboration, and improving patient outcomes through structured and thoughtful innovation.