Leader’s Episodic Change and Followers’ Continuous Change: The Case of Rakuwakai Otowa Hospital

: In a review of the existing literature dealing with organizational change, Weick and Quinn (1999) asserted that the contrasting organizational changes of episodic change and continuous change reflect the perspective of the observer. That is, an organizational change can be explained and described as being an episodic change or a continuous change; however, no specific examples were given. The example of change in the Rakuwakai Otowa Hospital discussed in this paper is explained by a leader as being an episodic change, but the same situation is described by a staff member, who is a follower, as being a continuous change.


Introduction
Many studies have dealt with organizational change, among which the one by Weick and Quinn (1999), which categorized change into episodic change and continuous change, is frequently cited (3,347 times as of December 7, 2018, according to Google Scholar). Episodic change is intermittent, intentional change that occurs sporadically in the activities of an organization. Conversely, continuous change is change that occurs spontaneously, on a regular basis, and with many small adaptations.
Studies frequently cited in the field of organizational change assume that sporadic, non-continuous change and change that occurs over and over again with small adaptations are two different types of change and cannot occur simultaneously (Brown & Eisenhardt, 1997;Meyer, Brooks, & Goes, 1990;Romanelli & Tushman, 1994;Tushman & Romanelli, 1985).
On the other hand, according to Weick and Quinn (1999), these two types of changes reflect differences in the perspectives of observers. When observers view change from the perspective of the overall organization, or the macro level, they consider change that occurs over a long period of time to be a revolutionary event in an episode of the organization. However, from a micro-level perspective within the organization, that change may be considered to be a continuous adaptation and adjustment. This means that a single organizational change can be portrayed as both an episodic change and a continuous change.
However, Weick and Quinn (1999) did not give any specific examples, and subsequent studies have employed their concepts of episodic change and continuous change as resources to determine types of reform. For example, Orlikowski (1996), Plowman, Baker, Beck, Kulkarni, Solansky, andTravis (2007), and Dutton, Ashford, O'Neill, and Lawrence (2001) assume that change that occurs at a certain point in time is either episodic or continuous and understand this change only on either a macro level or a micro level.
This study uses the case of Rakuwakai Otowa Hospital (hereinafter, "Otowa Hospital") to explain the assertions made by Weick and Quinn (1999). Although Otowa Hospital moved from having its employees place priority on technology to having them place priority on the experiences of its patients undergoing medical care, what management leaders viewed as episodic change was regarded by followers as continuous change.

Case Study
The case of Otowa Hospital, a 548-bed general hospital that provides advanced medical treatment, primarily acute care, is described below in three phases: Phase 1, pre-EMR implementation; Phase 2, EMR implementation; and Phase 3, post-implementation. In addition, during Phase 2, when particularly large changes were objectively observed, we introduce the question of what changes were occurring between the leaders and followers.

Phase 1: Pre-EMR implementation
Since 1980, hospital managers had constantly told the staff to look at things from the patients' perspective and repeatedly explained the organizational philosophy that they had designed. In practice, however, it was difficult for busy staff members to think about the patients' perspective when providing services; hence, the doctors and other staff prioritized their own behavior and thinking. In addition, staff members belonging to other professions or working on the hospital floor did not talk to each other about service very often. Patients and their families, therefore, voiced dissatisfaction over wait times, patient flows, and responses. Some staff groups improved on their own. However, one of the hospital's managers,

Abe
Kojima, examined these improvements and found that they had been achieved from the perspective of the medical personnel and devised within their own scope of work. Kojima, therefore, thought that the improvements that were more from the patients' perspective should be made. 1

Phase 2: EMR implementation
Kojima decided to change the record-keeping medium from paper to electronic medical records (EMR) in 2001. This was to accomplish two objectives. The first was to improve work efficiency. At the time, the aging population and advances in medical technology were increasing the necessity of responding to patients' needs. Kojima thought that using EMR would facilitate information processing and allow the staff to focus on high value-added tasks.
Second, in going from the preparation to the implementation of EMR, Kojima thought that it would be good for the staff to gain experience in thinking and collaborating from the patients' perspective and then use that experience in their everyday work.
The results obtained from preparation and subsequent implementation are as follows.

Preparation for EMR introduction
(1) Forming a project team: Middle-level managers A project team of eight people from middle management in various professions was created. The team members liaised with the hospital floor, Kojima, and others in management and led the way in operational problem-solving.
(2) Visiting another hospital: Representative of staff members Along with the management and project team members, staff members representing hospital wards, the outpatient department, and other areas pitched in by visiting other hospitals that had already implemented EMR. They underwent treatment at these hospitals as patients and shared what they had learned with the other project team members. Through these experiences, the staff acquired an understanding of how EMR is used and the impact of their responses on patients.
Meanwhile, Kojima and the project team members used their visits to other hospitals to predict the changes that would occur before and after EMR implementation and recorded data regarding what could happen when those changes were made (work hours, wait times, patient satisfaction, etc.) (3) Rehearsal: All staff members After all staff members learned how to use EMR, Kojima held a consultation rehearsal for all the staff on a non-consultation day in the outpatient department. All the doctors used EMR in their consultations that day, and non-doctor staff members played the part of patients receiving consultations. Afterward, the staff members who had acted as patients filled in a questionnaire about how they felt during the consultation. From the questionnaire, the doctors found that there were issues in wait times, patient flow, and staff attitudes. They then took the initiative to discuss among themselves ways in which to improve their interaction and behavior with patients.
A second rehearsal was held on a later date, and this time, the consultation process went smoothly, with doctors receiving better feedback from the patients.
(4) Changes that occurred at each profession meeting Before EMR was implemented, meetings of the various professional groups were only attended by the professionals in that group. However, because all the professions use EMR, these groups needed to converse with each other; hence, project team members attended meetings of those in other professions. This led to staff members realizing that issues could be resolved by speaking with other groups.

Outcome of EMR introduction
The implementation of EMR had two kinds of effects. First, work became more efficient. In the outpatient area, for instance, the reduction in low value-added work led to a reduction in the number of tasks performed, from 38 to 14, and the average wait time per patient went down, from 72.7 minutes to 33.6 minutes. Consequently, the staff was better able to respond to patients' needs, and patient satisfaction improved (Ku & Kubo, 2006).  Figure 1 shows the perceptions of Kojima, the leader, and the followers on the staff regarding how much and when change took place at Otowa Hospital. As stated earlier, in Phase 1, the staff had made some improvements on their own to effect changes in the status quo prior to EMR implementation; however, Kojima thought that these efforts were inadequate. In Phase 2, preparation for EMR implementation and the implementation itself was done in a short period of time, and Kojima thought that the services provided by the staff had changed markedly, stating that the staff had become more helpful and began to think about things from the patients' perspective.

Perceptions of change between the leader and followers
On the other hand, the staff viewed the goings-on within the organization before and after EMR implementation as a series of small changes. The staff felt that the change that occurred over that period was just a change in the method of daily record-keeping and did not think that any major change had occurred in how they were providing their services. Moreover, through reporting by the staff in the hospital newsletter and at meetings and via objective feedback from patients, the staff gradually became aware of this understanding of the changes that occurred before and after EMR Abe implementation like Kojima previously awared of that. 2 In other words, as shown in Figure 1, there was a perception gap between the leaders and the followers regarding the continuity and scale of the changes and when they became aware of these changes.

Phase 3: After EMR introduction
Kojima thought that through various projects and updates to EMR, the staff would continue their new post-EMR implementation behavior. The events that occurred during the two projects and an EMR update are presented below in chronological order.

In-house open recruitment project
In the late 2000s, Kojima created a project in which the staff would 2 Sato (2015) and Kosuge and Takahashi (2016) also point out that management and employees have different perceptions of new initiatives.

Renewal of EMR
The hospital's EMR system was updated in 2011. Just as when the system was originally implemented, a project team was formed for the update, the team visited other hospitals that were already using EMR, and rehearsals were held. By rethinking the work with professionals and staff members in other areas, staff members were again able to gain an awareness of the importance of service that consider patient flow. Furthermore, they applied what they learned to their everyday behavior and encouraged service emphasizing patients' lives during medical treatment.

Smile project
In 2016, Kojima created a project that would focus on instant solutions targeted at improvements to everyday troubles.
For example, in one hospital ward, nurses were spending two hours each day on administrative work related to rehabilitation and could not find enough time to visit patients. They therefore requested the help of a rehabilitation professional in another area of the hospital. The rehabilitation professional said that the administrative work could be handled quickly by the rehabilitation office and offered to hand over the work to that office. The nurses were then able to use the extra time to respond to the needs of patients.
As we have seen, after Otowa Hospital implemented EMR, continuous change took place with EMR and other projects being updated so that the new behaviors could be maintained.

Discussion and Conclusion
As was noted by Weick and Quinn (1999), in the case of Otowa Hospital, perception gaps occurred between the management leader and the followers regarding the size of changes and when those changes occurred. In particular, in relation to the episode, the leader, who viewed the change from a macro perspective, thought that a major change had occurred over the short time period between preparing for EMR implementation and the implementation itself but later understood that those changes had been small and occurred repeatedly. Conversely, staff members regarded those same changes as being perpetual and ongoing.
In other words, unlike prior studies that implicitly assumed there to be only one model for a one-time organizational change (Brown & Eisenhardt, 1997;Meyer et al., 1990;Orlikowski, 1996;Plowman et al., 2007;Romanelli & Tushman, 1994;Tushman & Romanelli, 1985), the same change can be both an episodic change and a continuous change, depending on the perception of the observer.
In the future, using the perspective that gaps in perception will occur between leaders and followers, a more detailed analysis could be conducted of the process, whereby leaders and staff members on the floor work together to effect change.
Scientific Research Results, Grant Number JP16HP2004.