CKD INTERVIEW 2Illness and Disease Management CKD In

CKD INTERVIEW 2
Illness and Disease Management CKD Interview
Betsy Quinones
February 27, 2021
NSG4055- Illness And Disease Management across a Lifespan
Professor Amber Mccall
Illness and Disease Management CKD Interview
Introduction
Mr. X has a medical diagnosis of stage 3 chronic kidney
disease. According to the interview, he has a little bit of an
understanding of his condition, though his level of awareness is
low. He pointed out that the condition has changed his
relationship with family and friends. The quality of life of
individuals is closely related to the quality of life of those
around them (Golics, 2019). In this journal, Golics further went
and published that most chronic illnesses have the same impact
on the family. In this case, chronic kidney disease has disrupted
the psychological, emotional, and normal functioning of the
family and some friends of Mr. X. Even the study advocates for
a family-centered approach to care the disruptions brought

about by the disease process negatively affect the wellbeing of
the patient.
According to the stages of grief, Mr. X is at the level of
acceptance same to the family. This stage means the patient has
understood and accepted what the condition means to his life.
The family members and friends have also reached the
acceptance stage and are with him in his hard moments.
Acceptance is not necessarily an uplifting stage of grief, it may
mean that there may be more good days than bad but there may
be still bad – and that is ok (Holland, 2018).
Coping mechanisms
Dealing with chronic illnesses requires coping skills to avoid
sinking into depression. As for Mr. X, the main coping skill is
lowering expectations of the awaited outcome. For example, if
his blood has been taken for waste analysis before dialysis when
the results come, he has trained himself not to expect much to
avoid disappointments if otherwise. In addition to lower
expectations, Mr. X also asks for help if need be, especially
financial support. Change of source of stress and distance fr om
the source of help has also been practiced by Mr. X to cope with
stress. Finally, maintaining emotional composure has also been
deployed by the patient to avoid stress (Coping skills and
strategies, 2017).
Treatment of CKD
The treatment for Mr. X is partly symptomatic and largely
therapeutic. For example, on occasions where the hemoglobin
levels are low, he is given ferrous sulfate tablets or iron
injections to control anemia. Diuretics such as furosemide are
given to the patient to control edema. He is put on
antihypertensive drugs to control his blood pressure which is
the suspected root course of his condition. He also attends two
sessions of hemodialysis each week to eliminate wastes from
the blood (Medication, 2019).
Support aspects
The support aspect of chronic kidney disease is social,
emotional, and psychological. The patient requires family and

friends to offer social and emotional support to provide the
patient with strength and the will to take treatment accordingly.
Given that the condition comes with a lot of stressors,
psychological support by a trained psychologist would be
necessary to ensure the mental health of the patient is in good
condition.
In conclusion, the following information will be necessary
indirect development of a care plan for a group of patients with
chronic kidney disease because the disease process is similar
and that the complications of the condition are the same and
may only vary from patient to patient. The treatment of
complications with vitamin D and antihypertensive will be the
same across board and dialysis too (Section 10: The role of
social, cultural, psychological, and family relationship factors
in the etiology of disease and illness, 2018).
References
Fishbane, S., & Spinowitz, B. (2018). Update on anemia in
ESRD and earlier stages of CKD: core curriculum 2018.
American Journal of Kidney Diseases, 71(3), 423-435.
Golics, C. J., Basra, M. K. A., Finlay, A. Y., & Salek, S.
(2013). The impact of the disease on family members: a critical
aspect of medical care. Journal of the Royal Society of
Medicine, 106(10), 399-407.
Holland, K. (2018, September 25). What You Should Know
About the Stages of Grief. Healthline.
https://www.healthline.com/health/stages-of-grief
Medication. (2019). Kidney Care UK.
https://www.kidneycareuk.org/about-kidney-
health/treatments/medication/
Section 10: The role of social, cultural, psychological, and
family relationship factors in the etiology of disease and illness.
(2018, February 21). Health Knowledge.
https://www.healthknowledge.org.uk/p ublic-health-
textbook/medical-sociology-policy-economics/4a-concepts-
health-illness/section7/activity4/answers
Stressors: Coping Skills and Strategies. (2017). Cleveland

Clinic. https://my.clevelandclinic.org/health/articles/6392-
stress-coping-with-lifes-stressors
Zhang, L., Zhang, P., Wang, F., Zuo, L., Zhou, Y., Shi, Y., ... &
Wang, H. (2018). Prevalence and factors associated with CKD:
a population study from Beijing. American Journal of Kidney
Diseases, 51(3), 373-384.
Appendix
1. Does the patient have a family history of cardiovascular
disease or diabetes?
Yes, cardiovascular disease from the father of Mr. X.
2. What is the patient’s level of awareness about CKD?
Low level.
3. What is the degree of kidney damage, and are there any
complications that have been developed?
Stage 3B moderate CKD, complications are anemia, gout, and
fluid buildup.
4. When did the patient start experiencing symptoms?
2 years before diagnosis.
5. Does the patient have hypertension or postural changes?
Yes.
6. Does the patient experience any chest pain? If yes, what are
the location, nature of radiation, and severity?
Chest pains and discomfort are usually felt on the left side, the
pain is moderate.
7. What does the laboratory result reveal about the patient’s
fluid and electrolyte balance?
GFR 30-59
8. Is the patient undergoing dialysis? If yes, then for how long?
Yes, twice per week
9. What is/are the possible cause of the patient’s CKD?
Hypertension
10. Which type of treatments or drugs is the patient receiving
currently, and what is the response?
High blood pressure medications, medications to treat anemia,

medication to relieve swelling, medication to lower cholesterol,
and a low protein diet.
11. Are the patient’s caregivers adequately aware of the
evidence-based management practices of CKD?
Yes.
12. What are the results obtained from evaluating heart sounds,
peripheral pulses, vascular congestion, capillary refill, and
temperature measurement?
Temp 37 C, capillary refill of 4seconds, a peripheral pulse of
85bpm,
13. What is the level of the patient’s activity intolerance?
Insufficient physiological energy to complete required daily
activities.
14. What is the level of pain experienced by the patient?
Moderate pain.
Habits as
Change
Levers
By Daniel Denison and Levi Nieminen
Lasting changes must be embedded
deeply within the fabric of an organization.
Changes that don’t “stick” won’t improve
the performance or effectiveness of an
organization. A useful framework for
understanding the deeper human and social

elements of organization change is the
organizational culture perspective.
O
ver 30 years of scholarship has shown
that culture can be either a potential
springboard or a potential barrier to
change within organizations, and that ultimate-
ly, culture is a key driver of business performance
(Sackmann, 2011). Recent advancements in
practice now allow change professionals to use a
well-researched set of tools to diagnose organiza-
tions and to plan interventions to create change.
VOLUME 37/ISSUE 1 — 2014 23
➤
24 PEOPLE & STRATEGY
Embedding Change in
“the Deep Levels of
Culture”
The “iceberg model” is the dominant way of
representing the multiple layers of culture
(Schein, 1985).Above the water’s surface,
artifacts are the visible, tangible manifesta-
tions of culture in various attributes of the
physical workplace. Just below the surface,
espoused values characterize the preferences
and aspirations that are shared within the

organization and which contribute to a
shared sense of identity and meaning. Behav-
ioral norms and work practices also reside
at this level, constituting “the way things are
done around here.” And in the deeper water,
far below the surface, lie the beliefs and
assumptions—the underlying mindsets—
which shape the culture at a fundamental
level and influence its manifestation at all
other layers. Together, these visible and
invisible layers comprise the culture of an
organization (see Exhibit 1).
As a conceptual model, the iceberg creates
an awareness of depth for practitioners, rein-
forcing the idea that much of what drives
behavior in the organization is hidden from
plain view. This, of course, encourages us all
to look for those deeper factors, making nec-
essary a set of diagnostic tools and method-
ologies that are up to the task. The iceberg
also focuses the point of change intervention
at the deepest level, at the layer of underlying
beliefs and assumptions. According to the
theory, it is this deepest layer that is the most
consequential for the organization—this is
the part of the iceberg that “sinks the ship”—
and hence where the most crucial action
needs to be focused. Accordingly, change
needs to be embedded at this same depth to
have a lasting impact within the organiza-
tion.
The iceberg model has had a profound influ-
ence on both the academic study of culture
and the way in which practitioners affect

culture change in organizations. This three-
level model has often been interpreted to
suggest that changes must be targeted at one
of the three different levels. Interventions at
the levels of visible behaviors or values are
sometimes downplayed in favor of the points
of leverage that exist in “the deeper levels of
culture.” Because beliefs and assumptions
are cognitive, in that they reside in the mind-
sets of people, th is sug gests the most
impactful interventions ought to be “psy-
chological” in nature. In a practical context,
this frames the intervention in a way that
might either be construed as ‘off limits’ (i.e.,
not modifiable) or “off putting” to business
leaders (i.e., generating skepticism or nega-
tive stereotypes).More importantly, we
think it misses an opportunity to address the
targets of change that span across these three
levels emphasized by the iceberg model.
The habits and routines that span these three
levels of culture guide much of what happens
within organizations, yet they have received
little attention from organizational scholars
For the individual, habits are both functional
and, sometimes, problematic. Personal habits
provide structure and constancy, reduce
uncertainty, and free up cognitive resources
for a select number of complex tasks. Habits
can also be dysfunctional, such as when they
are expressed rigidly despite a context mis-
match (i.e., mindlessness) or when individuals
fail to appropriately switch between auto-

matic and effortful behavior (Luis & Sutton,
1991). The powerful effect of personal habits
has been studied in a wide range of situations,
from healthcare to the workplace and com-
petitive sports (e.g., Grant & Schempp, 2013).
Organizations, too, have habits and routines (i.e.,
larger, sequenced bundles of habits) which set them
apart and provide internal structure.
and practitioners. It is here, in these “auto-
matic” and repetitious behaviors that practi-
tioners can find a powerful point of leverage
to affect the change process, deep within
organizations.
Habits: Old and New,
Good and Bad
Drawing on neuroscience, Graybiel (2008)
provides a technical definition of habits as the:
sequential, repetitive, motor, or cog-
nitive behaviors elicited by external or
internal triggers that, once released,
can go to completion without con-
stant conscious oversight (p. 361).
Decades of research has shown that habits
are:
• predominantly acquired through experi-
ence and interaction with the environment;
• are repetitious and can become resistant to
change, such as in addiction;

• are performed with little conscious thought
or effort;
• can be elicited by environmental or inter-
nal cues; and finally,
• the expression of habits can be behavioral
or cognitive, such as in habits of thought
(Graybiel, 2008).
Habits also appear and are enacted with
consistency among and within groups of
people, from families to societies. Organiza-
tions, too, have habits and routines (i.e.,
larger, sequenced bundles of habits) which
set them apart and provide internal structure
(Pentland & Feldman, 2003). Habits are
inherently cultural. They reflect all three
levels; the underlying assumptions about
“the way we do things around here,” the
values that those assumption represent, and
the visible behavior and artifacts that we can
see in action. Functionally, they capture the
organization’s specific knowledge that has
been created over time and then translate
that knowledge into action in an efficient
way that conserves energy and resources.
Denison, Hooijberg, Lane, and Lief (2012)
developed a useful framework (see Exhibit
2) that puts habits and routines into one of
four categories based on two aspects: good
or bad and old or new. Each combination
calls for a different set of possible actions.
Bad, Old Habits: Unlearn and Leave Behind.
Bad habits are “like chains that are too light to

feel until they are too heavy to carry,” as War-
ren Buffett said. Often, we are too late to
realize how restrictive our old habits have
become and miss the opportunity to do some-
t h i ng ab out t he m . U n le a r n i ng t he s e
well-established habits can be very difficult,
but that is exactly what needs to happen. To
leave behind bad, old habits, organizations
need a clear focus on the areas of consensus
about these targets for change. With a clear
focus, organizations can start building prog-
ress and momentum and develop the experience
and conviction to take on bigger challenges.
Good, Old Habits: Preserve and Strength-
en. In the midst of organizational change,
it can be easy to forget to protect those ele-
m e n t s of t h e c u lt u r e t h at m ad e t h e
organization great. Some of the old and
well-established habits and routines from
an organization’s past are still essential to
the organization’s success in the future.
They are clearly understood by the organi-
zational members, make up a key part of
the organization’s mindset, and are closely
linked to other aspects of the organization’s
functioning. Therefore, it is vital for orga-
nizations to clarify the core habits and
routines that they need to preserve and
strengthen.

Bad, New Habits: Rethink and Try Again.
During the time of change initiatives, orga-
nizations attempt to create various new
habits and routines. However, cultu re
change requires a lot of trial and error. Cre-
ating a new set of habits and routines does
not always mean that they are going to work
as intended the first time and fit the situation
well. The culture of every organization rep-
resents its wisdom accumulated through
years of experimentation. Enlightened trial-
and-error is critical when trying to create the
new habits and routines to transform an
organization’s culture.
Good, New Habits: Invent and Perfect. The
opportunity to create new habits might be the
most exciting part of the culture change pro-
cess. However, creating new habits and
routines is difficult, as there are several pieces
to the puzzle. Mindset, behavior, and systems
must all change together to reinforce the
adaptation process for the organization.
Organizations cannot simply change people’s
mindsets, prescribe a new set of behaviors to
follow, or mandate a new system. Instead,
organizations need to persistently push hard-
er and harder on all three of those levers at
once, until signs of success manifest and
encourage others to join in to help build the
momentum.
Analyzing an organization’s culture as a
bundle of habits that fit into these four cat-
egories serves to focus the discussion on key
areas of consensus that reveal a targeted and

practical agenda for change.
When driving successful changes, leaders
choose the “keystone habits” that can have
the biggest impact on the organization.
Below are three real case examples that illus-
trate the role of keystone habits in creating
successful and sweeping change in organiza-
tions.
Identifying Keystone
Habits: Three Case
Examples
One of the inspirations for our attempts to
understand how organizations identify the
keystone habits that are the most promising
targets of intervention comes from Charles
Duhigg’s best-selling book, The Power of
Habit (2012). In this book, Duhigg tells the
story of the early days of Paul O’Neill’s term
as CEO at Alcoa. After a long struggle to find
some targets for improvement that would be
supported by both the management and the
workers at Alcoa, O’Neill decided to put his
emphasis on safety. During a time when
there was little alignment between manage-
ment and the workers, this was the area that
he saw as being most likely to build collabo-
ration. The organization set the goal of
having zero injuries, and the main point of
intervention was that all injuries, world-
wide, must be reported to the CEO’s office
within 24 hours. The best way to solve this
problem, or course, would be to have no
injuries. Though the goal of zero injuries was
not achieved, both management and the

unions learned to move fast with a level of
transparency that was unprecedented.
This safety effort took serious commitment
by everyone involved, but in the end it was
very effective. The unexpected impact was
that changing this single set of habits and
routines concerning the way that the organi-
zation managed safety incidents created a
level of transparency that was new to the
organization. The company discovered that
Often, we are too late to realize how restrictive our
old habits have become and miss the opportunity to
do something about them. Unlearning these well-
established habits can be very difficult, but that is
exactly what needs to happen.
EXHIBIT 1. ICEBERG MODEL OF ORGANIZATIONAL
CULTURE
➤
26 PEOPLE & STRATEGY
it could share information about perfor-
mance, about best practices, about business
opportunities to a much greater degree than
it had in the past. So, these underlying beliefs
about transparency and collaboration spread
broad ly t h roug hout t he orga n i zat ion.
O’Neill credits this process with leading
Alcoa to a dynamic, new level of perfor-
mance that lasted for most of the decade.

A second habit change example involves the
Metropolitan Transit Authority (MTA) of
New York City, which manages all public
transportation in and out of the city. This
includes a high-volume subway system,
which carries an average of 5.4 million pas-
sengers per day (1.6 billion per year)!
Servicing the 820 miles of track comprising
the subway system is a major and ongoing
task, one of several maintenance functions
that are crucial to keeping the trains moving
and the people on them safe. In the past, all
maintenance to the tracks was done on the
weekends, late at night when the train vol-
ume was lowest. With the crews repairing
the tracks in the short windows between
oncoming trains, the maintenance work was
slow, expensive, and quite dangerous. How-
ever, the old strategy was deeply engrained
in one of the MTA’s strong points of pride:
keeping the trains moving, no matter what
and at all costs! The keystone habit in this
case directly challenged this point.
In 2010, the subway system experienced a
number of high-profile safety incidents, cul-
minating in a worker fatality in April and
then a blizzard in December that left some
passengers stranded in train cars for over 12
hours without food, water, or heat. Follow-
ing these incidents, an u nprecedented
decision was made to stop the trains. The
president of the Department of Subways,
Carmen Bianco, architected a program
called FastTrack to identify and shut down

whole sections of track for maintenance
beginning at 10 p.m. and reopening the fol-
lowing day at 5 a.m. For the first time, this
allowed ser vice workers uninterrupted
access to the tracks, signals, cables, and
other rail components. Initially, the public
reaction was a widespread outcry. Subway
passengers, like MTA workers, were unac-
customed to any interruption to service.
Over time, however, the sweeping, positive
effects were staggering! FastTrack improved
productivity, saved money (estimated sav-
ings of $16.7 million in 2012), cut accident
rates nearly in half, and increased train reli-
abi l it y by ne a rly 5%. T he suc c e ssf u l
implementation of this program was no
small strategic and operating feat, but at the
core, the MTA achieved a shift in one fairly
simple keystone habit: they can stop the
trains.
A final example involves GE Healthcare Chi-
na.1 GE entered an emerging Chinese market
in the early 1990s. In the decade that fol-
lowed, GE expanded its anesthesia business
through the acquisition of two companies,
Datex-Ohmeda and Zymed, both of which
were strong global brands with a presence in
China. Zymed became the center-point of a
new and growing business, Clinical Systems
Wuxi (CSW) in Wuxi, China. CSW was
responsible for the design, engineering, and
production of anesthesia equipment. The
rapid grow th of this business exposed
increasing weaknesses in quality and declin-

ing customer reputation, eventually resulting
in the business halting distribution of prod-
ucts for a period of time.
In 2007, a new general manager was appoint-
ed, Matti Lehtonen. It was clear to Lehtonen
that restoring quality and customer service
should be the top strategic priorities moving
forward. Lehtonen and his senior team
implemented a simple yet extremely power-
ful intervention by requiring their engineers
to visit operating rooms and witness their
anesthesia equipment being used in live sur-
gical procedures. In this case, a single
habit—sending people out to where the cus-
tomers are—had a profound set of cascading
effects. Seeing the equipment in use added
new meaning and clarity about the purpose
of the work and provided the engineers with
1 For more on this case, see Denison, Hooijberg, Lane, &
Lief (2012).
a deeper appreciation and understanding of
the specific needs of multiple end users,
including the patients, the doctors and nurs-
es, and the hospitals and insurers. Over time,
this keystone habit did help to restore qual-
it y a nd c u s tom er reput at ion . I t a l s o
broadened the role and skill set of the engi-
neers and became a focal point for talent
recruitment and retention. Moreover, it
opened up new insights and new product
innovations, and by 2010, one of these new
products was shipping to emerging markets
all over the world!

From these case examples we can begin to
learn some useful principles for targeting key-
stone habits as high impact areas of action.
Below, we outline three principles for change
management professionals to consider.
Principles for
Intervening on
Keystone Habits
Principle 1: The diagnostic process
should differentiate keystone habits
from ordinary habits by looking for
impact and interconnectedness.
Like most change efforts, the process begins
with diagnosis. The cascading effect seen in
Alcoa was described by Duhigg as seren-
dipitous, but acting intentionally to modify
or build keystone habits calls for a reliable
diagnostic process that pays attention to the
right factors. Practitioners need to develop
the skills (and methodologies) to identify
and distinguish keystone habits from ordi-
nary habits. Each of the case examples above
highlights two interrelated factors that can
EXHIBIT 2. CHANGING CULTURE BY CHANGING HABITS
AND ROUTINES
G
o
o
d

Preserve
&
Strengthen
Invent
&
Perfect
B
a
d
Unlearn
&
Leave Behind
Rethink
&
Try Again
Old New
Graybiel, A. M. (2008). Habits, rituals, and
the evaluative brain. Annual Review of Neu-

roscience, 31, 359-387.
Louis, M. R., & Sutton, R. I. (1991). Switch-
ing cognitive gears: From habits of mind to
active thinking. Human Relations, 44, 55-76.
Feldman, M. S., & Pentland, B. T. (2003).
Reconceptualizing organizational routines
as a source of flexibility and change. Admin-
istrative Science Quarterly, 48, 94-118.
Mallidou, A. A., Cummings, G. G., Schalm,
C., Estabrooks, C. A. (2012). Health care aides
use of time in a residential long-term care unit:
A time and motion study. International Jour-
nal of Nursing Studies, 50, 1229-1239.
Sackmann, S. A. (2011). Culture and perfor-
mance. In N. Ashkanasy, C. Wilderom, & M.
Peterson (Eds.), The handbook of organiza-
tional culture and climate, 2nd ed., 188-224.
Thousand Oaks, CA: Sage Publications.
Schein, E. (1985). Organizational culture and
leadership. San Francisco, CA: Jossey-Bass
New habits are unlikely to take hold in organizations
without diligent and concerted efforts for socializing
and embedding them.
help to focus the diagnostic process: key-
stone habits are linked to the organization’s
effectiveness (impact), and keystone habits
are tightly interwoven with other habits,
routines, and processes in the organization
(inte rconn ec tedn ess). T h is means that

intervening on keystone habits is likely to
have a cascading effect, so that change
started in one place leads to many other
changes in many other places. For example,
the act of eating together strengthens the
social bonds within the family but also
aligns a number of the habits and routines
leading up to and following the mealtime.
Principle 2: Keep the scope of inter-
vention small by tapping into the
right habit(s) and affecting scalabil-
ity through the repetition of this
habit.
When it comes to intervening on keystone
habits, the “scalability” of impact is hardly
determined by the size or scope of the inter-
vention. Habits are repetitious. Some are
repeated on a daily or weekly basis and oth-
ers moment to moment. This is a powerful
reminder that the best interventions will
stay focused and tap into the right habits
rather than attempting to “boil the ocean.”
As one example of a small habit with large
i m p l i c a t i o n s , M a l l i d o u , C u m m i n g s ,
Schalm, and Estabrooks (2012) found that
minor interruptions in nurses’ interactions
with patients, such as when called to assist
another patient or staff member, have a
significant deleterious effect on patient care
and health outcomes. A simple but power-
f u l i nter vent ion i n t h is contex t cou ld
redefine the keystone habit as “staying with
your patient to completion of each interac-
tion.” Of course, this might also require

unlearning some bad old habits, such as
responding to all requests, even the minor
and nonessential ones.
Principle 3: Use storytelling and
celebration to “ritualize” the perfor-
mance of keystone habits.
New habits are unlikely to take hold in orga-
nizations without diligent and concerted
efforts for socializing and embedding them.
We think that finding ways to reinforce key-
stone habits and make their performance
rituals within the organization is an important
part of the solution, so that the desired behav-
iors take on greater symbolic and psychological
meaning over time. The meaning of rituals is
often created and reinforced through storytell-
ing and celebrations, or as Durkheim
suggested, through the communication of
social norms that distinguish the “sacred from
the profane” (as cited by Boyce, Jensen, James,
& Peacock, 1983). These are opportunities for
the organization, often leaders, to clarify the
value of the new, good habits and the need to
extinguish the bad, old ones.
Conclusion
Viewing organizational cultures as bundles
of habits and routines, we believe that “key-
stone habits” in particular can serve as
powerful leverage points for change manage-
ment professionals seeking to embed their
work deep within organizations. Daunting as
culture diagnosis and intervention may be,

focusing on small habits with big implications
might be the best place to start and a great
way to ensure that the change does far more
than scratch the surface.
References
Boyce, W. T., Jensen, E. W., James, S. A., &
Peacock, J. L. (1983). The family routines
inventory: Theoretical origins. Social Sci-
ence and Medicine, 17, 193-200.
Denison, D., Hooijberg, R., Lane, N., Lief,
C. (2012). Leading culture change in global
organizations: Aligning culture and strate-
gy. San Francisco, CA: Jossey-Bass.
Duhigg, C. (2012). The power of habit: Why
we do what we do in life and business. New
York: Random House.
Grant, M. A., Schempp, P. G. (2013). Analy-
sis and description of Olympic gold medalists’
competition-day routines. The Sport Psy-
chologist, 27, 156-170.
Daniel Denison is Professor of
Organization and Management
at the I nternational I nstitute
for Management Development
(IMD) in Lausanne, Switzerland
and Chairman of Denison Con-
sulting. Since receiving his Ph.D.
in Organizational Psychology
from the University of Michigan,
Dr. Denison has authored numer-
ous books and journal articles

describing his research and con-
sulting linking organizational
culture to bottom-line business
performance.
Levi Nieminen is the director of
the Research & Development
group at Denison Consulting in
Ann Arbor, Michigan. He com-
pleted his doctorate in Industrial
and Organizational Psychology
from Wayne State University. His
research focuses on the intersec-
tion of organizational culture and
leadership as interrelated drivers
of organizational effectiveness.
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Copyright of People & Strategy is the property of HR People &
Strategy and its content may
not be copied or emailed to multiple sites or posted to a listserv
without the copyright holder's
express written permission. However, users may print,
download, or email articles for
individual use.

By Steve H. Cady and
Joo-Hyung Kim
Unlike other capital investments, the
value of learning appreciates, rather than
depreciates.—Christopher Lee
The evaluation of OD interventions has
never been more promising than in this
era with the advancements of such tools
as data analytics; yet it remains challeng-
ing for organizations to utilize a proper
evaluation strategy. In this article, we begin
by exploring the paradox of competing
demands and then introduce a pragmatic
model for selecting the optimal evaluation
strategy by considering both the scope
and rigor of analysis and leveraging the
levels of evaluation from the field of train-
ing and development. We conclude with
reflections on evaluation from the perspec-
tive of Gestalt OD Theory and collective
consciousness.
In today’s world of artificial intel-
ligence, quantum computing, and data
analytics, we are on the cusp of demon-
strating the central importance of OD inter-
ventions to the health and vitality of the
systems we lead, consult, study, educate,
and serve (Shah, Irani, & Sharif, 2017; Boje

& Henderson, 2014). These advancements
have enabled us to examine more readily
how OD interventions positively impact the
organization across multiple contexts and
levels of analysis. For example, we are now
capable of directly linking change processes
to organizational performance (Pettigrew,
Woodman, & Cameron, 2016). Further, this
possibility does not stop with proving the
importance of OD interventions. Evalua-
tion tools enable us to learn from and tease
out the nuances, and more specifically
learn from interventions in order to
improve them for future applications.
These conditions above have set the
stage for an evolutionary leap in the field
of OD (Kleiner, 2015; Laloux, 2014; Lawler
& Worley, 2011). On a national level, the
US department of labor predicts that
behavioral science fields such as OD will
be serving the fastest growing occupa-
tions (Career Trends, 2016). Likewise, the
federal government has been supportive
of the utility of behavioral sciences, as can
be seen from the following statement:
“Where federal policies have been designed
to reflect behavioral science insights, they
have substantially improved outcomes for
the individuals, families, communities, and
businesses those policies serve” (Presiden-
tial Executive Order, 2016, p.1).
While we are on the cusp of a new era,
there are still challenges to be resolved. A

successful evaluation of OD interventions
is one of the difficulties many organiza-
tional practitioners and leaders confront.
The Paradox of Competing Demands
Assessing the efficacy of OD interventions
can be elusive, because it is dependent on
the required accuracy of analysis ( Terborg,
Howard, & Maxwell, 1980; Butler, Scott, &
Edwards, 2003). The greater the required
accuracy, the more rigorous and therefore
more costly the design. It is this tension
that describes the paradox of competing
demands (Cady & Milz, 2015; Cady, Auger,
& Foxon, 2010), which partly arises from
What We Can Learn from
Evaluating OD Interventions
The Paradox of Competing Demands
“In today’s world of artificial intelligence, quantum computing,
and data analytics, we are on the
cusp of demonstrating the central importance of OD
interventions to the health and vitality of
the systems we lead, consult, study, educate, and serve.”
50 OD PRACTITIONER Vol. 49 No. 1 2017
the reality that you “can’t have your cake
and eat it too.” The competing demands
present a polarity of the purpose (i.e. prove
and improve), and the cost (i.e. time and
money).

Purpose: Prove and Improve
Proving Questions
❑ How many people are expected to
be impacted by the intervention?
❑ Who is accountable for ensuring the
intervention is implemented?
❑ Who else has the legal and govern-
mental oversight?
❑ What were the political implications
for the OD group and champions of
the intervention?
The first dimension of prove and improve
relates to the intended purpose of the inter-
vention. OD professionals find themselves
defending interventions, proving that the
interventions had the intended impact
and added value to the bottom line. The
need for proof is about accountability for
results, while making the business case to
the skeptics. Because OD is considered to
be based on the softer behavioral sciences,
the role of evaluation can be undervalued
and oversimplified. For example, it is easier
to measure one’s blood pressure (hard
science) than one’s attitude (soft science).
Or, it is easier to measure cost savings from
“right sizing” an organization, than it is
to measure cost savings from a training

initiative.
All the while, a core value of OD is to
evaluate for the sake of learning, improv-
ing the intervention and leveraging its
strengths. In other words, the second aim
is to evaluate in order to improve the inter-
vention and the organization for the future.
This future focus is based on the desire
to understand how interventions worked,
identify the relatively important elements
of the intervention, advance theories, and
create more robust interventions.
Improving Questions
❑ How can the results inform us about
future applications?
❑ Will the intervention be used in the
future and, if so, how much?
❑ What are the uses for and scal-
ability of the intervention for
other settings?
❑ What is the expected impact on
the wellbeing and culture of the
organization?
In some cases, an accurate evaluation is
necessary to determine whether the inter-
vention should be continued or scaled for
other settings (Kirkpatrick, 1998; Nielsen
& Abildgaard, 2013). However, perform-
ing rigorous high quality evaluations of

all interventions is not always practical,
though it might appear ideal. It is a particu-
larly relevant challenge when considering
the competing paradox of time and money
(Cady et al, 2010).
Cost: Time and Money
Conducting evaluations can be costly
in terms of both time and money for all
stakeholders involved. If either is too high,
it is likely that the key decision makers will
decide against conducting an evaluation
altogether.
Time Questions
❑ What are the required details for
the design, data collection, and
reporting?
❑ What are the demands by leader-
ship on the evaluation?
❑ Who needs to be included in and
informed of the evaluation?
❑ How many competing interventions
are currently being implemented?
In terms of time, leaders will need to pull
people away from their typical tasks for
evaluations, such as being interviewed,
filling out surveys, and providing perfor-
mance data. This opportunity cost is not
always seen as a good use of time. Too
often, surveys are filled out and go into

the proverbial “black box,” never to be
mentioned again. This lack of closing the
loop is one of the biggest hindrances to
getting reasonable response rates. Further,
it erodes the trust of those impacted by
the intervention, not to mention the loss
of quality information, undermining the
future applications of the intervention.
Money may be another major determi-
nant of an evaluation strategy, especially
when outcomes are difficult to measure. It
is possible that the evaluation can be the
largest item in the budget for an inter-
vention. Therefore, if the financial cost
associated with an evaluation is beyond
expectation, it may lead the organization
to decide against conducting any evalua-
tion. Evaluation competencies are another
consideration. As you move to higher levels
of evaluation, the required sophistication
often surpasses the expertise of those
responsible for the intervention (Cady &
Milz, 2015; Cady et al, 2010), requiring
additional inputs such as training and out
sourced professionals.
It is possible that the evaluation can be the largest item in
the budget for an intervention. Therefore, if the financial
cost associated with an evaluation is beyond expectation, it
may lead the organization to decide against conducting any
evaluation. Evaluation competencies are another consideration.
As you move to higher levels of evaluation, the required
sophistication often surpasses the expertise of those
responsible for the intervention, requiring additional inputs
such as training and outsourced professionals.

51What We Can Learn from Evaluating OD Interventions: The
Paradox of Competing Demands
Money Questions
❑ What are the intervention-related
fees and staffing costs?
❑ How much are the opportunity
costs from doing or not doing
the evaluation?
❑ What are the technology, soft-
ware, materials, and logistical
requirements?
❑ How much of the intervention’s
budget has been allocated for
the evaluation?
You Can’t Have Your Cake, and Eat It Too
The competing demand comes from the
desire to prove the effect of an interven-
tion and improve it while minimizing the
associated costs. Although a focus on the
proving and improving of an intervention
may result in better outcomes, it will cost
more in terms of time and money (see
Figure 1). In this case, how do you find the
optimal point that balances the polarity of
the benefits and costs?
You can choose a costly evaluation

that bears important implications for the
organization or community. If there is a
long-term implementation plan for the
intervention, the intended impact is likely
vital to the future; further, demonstrat-
ing results in an objective fashion may be
necessary for continued funding. However,
there are also cases where a costly evalua-
tion is not plausible or desirable.
There may be no time or budget allo-
cated to the evaluation because evaluations
are often reactionary and not given enough
planning. For example, the whole evalu-
ation process might begin with a leader
simply saying, “Did that program work . . .
can you confirm that it was worth our time
and money . . . are we better off . . . we are
not done, right . . . oh, by the way, can you
provide an update focused on these ques-
tions at our meeting next week?” Moreover,
some believe that funds would be better
spent on additional interventions or even
argue that evaluations are just a bureau-
cratic mechanism for show. The perception
is that the outcomes of the process are so
obvious that it is not necessary to conduct
an evaluation (Cady & Milz, 2015; Cady et
al, 2010). In this case, you can choose a
less rigorous approach that will not only
give you some general guidance for the
intervention but also help persuade the
skeptics about the need for an evaluation.

Selecting an Evaluation Strategy
Evaluations can take place at a single level
or across multiple levels, and this is often
determined by the tradeoff of the compet-
ing demands. This multi-level nature of
evaluations has been originally adopted
in the field of training and development,
based on two prominent models: Kirk-
patrick’s Levels of Evaluation (1998) and
Phillips’ Return on Investment (1996).
As shown in Table 1, there are five levels
Table 1: Levels of Evaluation with Low and High Rigor Options
Level Focus High Rigor Example Low Rigor Example
I Attitude: How satisfied
are people?
A validated survey with established reliability
measures and limited open-ended questions
for qualitative analysis.
Three questions on a flip chart with a couple
of them scaled and a third open-ended
question.
II Knowledge: What do
people know?
Administer a test that addresses key concepts,
information, and policies related to the
initiative.
Ask questions in an open forum about the key

aspects of the initiative and make notes of
what you hear.
III Behavior: What are
people doing?
Conduct behavioral observations of people;
identify the frequencies of specific desired
behaviors related to the initiative.
Administer a short questionnaire asking
people to self-report their actions (verbal
assessment also acceptable).
IV Impact: What has been
achieved?
Compare specific key performance indicators
before, during, and after the initiative has
been implemented.
Gather reports from a short survey, emails,
and meetings with examples of what has been
achieved.
V Return: How much money
has been generated
versus spent?
Conduct a formal ROI analysis with key
personnel reporting on verified costs (e.g.,
waste, errors, and cycle time) and the financial
gains from the intervention.
Calculate a verifiable ROI. Provide documented
examples of best practices.

Conduct a pseudo ROI analysis with key
personnel reporting on estimated costs (e.g.,
waste, errors, and cycle time) and gains from
the intervention. Calculate a SWAG (serious
wild ass guess) ROI with anecdotal evidence.
Time & Money
P
ro
ve
&
Im
p
ro
ve
Figure 1. The Paradox of Competing
Demands in Evaluating OD Interventions
OD PRACTITIONER Vol. 49 No. 1 201752
of evaluation that progress from assess-
ing attitudes at Level I up to assessing the
Return on Investment at Level V. Kirk-
patrick’s Evaluation Model was originally
introduced in a trade journal, and was
later published in his book titled Evaluat-
ing Training Programs (1975). Then, J.J.
Phillips’ (1997) built on the Kirkpatrick’s

model by adding a fifth level: the Return
on Investment (ROI) framework. These
two perspectives have been integrated and
applied to a variety of change initiatives
(Phillips, Phillips, & Ray, 2015; Russ-Eft
et al., 2008), and we recommend that OD
professionals include these approaches in
their toolkit for the evaluation and inter-
vention design process. The two frame-
works will provide you with the common
language that is often used throughout
organizations among leaders and manag-
ers alike.
In Figure 2, we propose that you begin
your evaluation design process with iden-
tifying the competing demand of purpose,
namely the desire to prove and improve the
intervention.
Then, ascertain the availability of
time and money to implement the evalua-
tion. Figure 2 provides the options you can
choose from with regard to the amount of
rigor. For example, if you find yourself in
need of both proving and improving the
intervention, then it is recommended that
you use all five levels of evaluation. If you
have unlimited time and money, you are
in a position to provide the highest level of
rigor in your assessment. However, as we
have discussed, this is typically not pos-
sible. While the tools for data analytics are
available, the staffing and related analytical
costs are still considerably high (BI-Survey.
com, 2015; Microstrategy, 2014).

Rigor influences how formal and
planned an evaluation is, thus impacting
the validity and reliability of the results. In
addition, the scope of the evaluation can
change from examining the participants’
experiences to verifying the intervention’s
impact on the organization. Next, we will
walk through some scenarios using Table 1
as a guide to help you decide the level of
evaluation. Then, Figure 2 provides further
examples on the ways to conduct less rigor-
ous evaluations when there are limitations
on time and money.
Let’s start with a scenario in which
you want to both prove and improve a
team-level mediation intervention. When
conducting an evaluation with high rigor,
the scope is the most invasive and extreme;
it involves higher costs with a formal sur-
vey to assess reactions (Level 1), a test on
the mediation model being used (Level 2),
and the monitoring of the mediation
practices utilized (Level 3). The evaluation
also requires the evidence for supporting
high-leverage improvements while also
proving the degree of impact, such as the
frequency of mediations (Level 4), and
a well- documented ROI (Level 5). These
measures attempt to answer the following
questions, for example:
» How effective was the team mediation

intervention?
» How can it be more effective?
» What difference has it made?
» What errors have been averted?
» How much cost has been saved?
» What revenues have been improved?
All five levels of evaluation are to be
conducted in a formal and valid fashion by
trained research professionals.
Now, let’s consider a situation
where you find yourself in need of prov-
ing whether the intervention worked as
intended; however, you do not want to
improve the intervention for the future.
While the evaluation aims at assessing the
changes in operations and behaviors, the
focus is on the direct impact of the inter-
vention. In the case of the team mediation
intervention, this might involve assessing
the mediation practices utilized (Level 3)
and the number of mediations conducted
or the amount of time to resolution
(Level 4). These measures would be taken
before, during, and after the intervention
implementation.
The lowest level of evaluation, before
there is no evaluation required at all, is the
scenario where you do not want to prove
whether the intervention worked, yet you
need to improve it for future applications.
In this evaluation strategy, you would con-
duct Level 1, 2, and 3 evaluations. Here you

Ti
m
e
&
M
o
n
ey
Hi
ye
s
yes
yes
no
no
no
Prove?
Improve?
All Levels
(1–5)
Middle Levels
(3–4)

Low Levels
(1–3)
No Eval
Needed
Improve?
Lo
Figure 2. Evaluation Strategy Decision Tree
When conducting an evaluation with high rigor, the scope is
the most invasive and extreme; it involves higher costs with
a formal survey to assess reactions (Level 1), a test on the
mediation model being used (Level 2), and the monitoring
of the mediation practices utilized (Level 3). The evaluation
also requires the evidence for supporting high-leverage
improvements while also proving the degree of impact, such as
the frequency of mediations (Level 4), and a well-documented
ROI (Level 5).
BI-Survey.com
BI-Survey.com
examine the specific intervention’s impact
on individuals’ perceptions and behaviors.
For example, you might assess reactions
to the team mediation (Level 1) and check
if the mediation model has been properly
understood (Level 2). You might use three

questions on a flip chart to assess the sat-
isfaction level, and ask them to write down
the components of the mediation to check
the learning outcomes.
Within all of these strategies, you may
need to conduct a less rigorous evaluation
providing a rough understanding of how
to improve the intervention by gathering
information with limited resources in
a shorter time period. For example, you
may walk around the organization taking
note of changes, conduct an informal poll
during a meeting, and seek personal inputs
about the perceived impact of the inter-
vention (Table 1). Leaders may be asked to
estimate the approximate cost savings and
revenue improvements, thereby estimating
a pseudo-ROI.
Summary and Reflections
The process of evaluating interventions is
about determining whether the path you
are on has been the most effective strategy
efficiently executed for the system you are
in. In turn, this will influence how you
move into the future. The fundamental
premise of a good evaluation, as consistent
with the principle of the Gestalt Theory
of OD, is self-awareness on a large-scale.
Self-awareness serves as the starting point
of the whole energizi ng action cycle in the
Gestalt Group Cycle (Zinker, 1980); to be
able to figure out the future path, people

and the whole systems must be aware of
themselves. Likewise, as in the notion
of collective consciousness, group aware-
ness can act as a unifying force for taking
ownership in determining how to move
forward together (Tsoukalas, 2007).
The models presented here provide a
framework for considering the competing
demands and the trade-offs to be made.
Developing an effective evaluation strategy
is subtle, and grey areas are manifold. For
example, imagine you are working on the
decision tree model (Figure 2) and it sug-
gests that an informal SWAG (serious wild
ass guess) evaluation is the best option with
Levels 4 and 5, because time and money
are limited. Is this “bad”? We say “no.” The
reason is two-fold. First, getting leaders to
slow down and think through the questions
necessary to evaluate an OD intervention is
important. For example, a venture capitalist
conducts valuations using internal rates of
return (IRR), which are based on critical
assumptions. The value of these invest-
ments often dwarfs the costs of most OD
interventions; and, it is interesting to note
that IRR calculations are made with some
SWAG. Similarly, engaging leaders in the
analysis of the intervention’s impact is
about creating conscious and more mind-
ful decisions on the ways to improve the
organization. Second, if the leaders paying
for the intervention get feedback from cred-

ible peers that the intervention resulted in
a meaningful return on the investment,
they will deem the feedback a valid data
point. While this belief is a perception, it is
helpful to know key stakeholders’ collective
reality in order to figure out the next steps
for organizational change efforts. In short,
evaluations do not happen in a perfect
world; there are always compromises that
must be made.
The bottom line is this: if you can
achieve the intended purpose of the evalua-
tion, then you have found the balance with
the paradox of competing demands. You
may find that your desired evaluation strat-
egy differs significantly from those you are
serving. As a result, go back to the drawing
board and rethink what is most important
to you, which may require renegotiating
expectations with key leaders and other
stakeholders.
In closing, the evaluation of OD
interventions supports the development of
a learning organization, and this is where
a consultant as an intervener can play an
important role in helping the organization
in service or disservice of itself. In provid-
ing the system with a better understanding
of itself through rigorous evaluations, the
system will change its thinking paradigm
and move toward a more intentional way
of self-organizing (Nevis, 2013). When the
system begins to change its thinking para-

digm, the learning has begun and “action
learning” occurs. This shift in thinking
and learning is what will lead to new orga-
nizational habits that result in long-term
sustainability.
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Interested in learning more about the
differences OD makes? See the call
for articles on page 5.
Steve Cady, PhD, is a professor,
author, speaker, and consultant.
He is a graduate faculty mem-
ber in the Bowling Green State
University Master of Organiza-
tion Development Program. Cady
is the co author of The Change
Handbook, author of Stepping
Stones to Success and PBS DVD
titled Life Inspired. He is also the
Chief Editor and Curator for the
BKpedia Change & Innovation
Collection. He can be reached at
[email protected]
Joo-Hyung Kim is an MBA can-
didate at Bowling Green State
University. She earned her
bachelor’s degree in Business
Administration from Korea
University. Her research interests
include judgment and decision
making, emotion, and applicant

attraction. She can be reached
at [email protected]
http://psychology.about.com/od/psychologycareerprofiles/p/iops
ychcareers.htm https://blog.dol.gov/2015/03/15/the-10-fastest-
growing-jobs/
http://psychology.about.com/od/ps ychologycareerprofiles/p/iops
growing-jobs/
growing-jobs/
growing-jobs/
http://www.strategy-business.com/article/00344?gko=10921
http://www.strategy-business.com/article/00344?gko=10921
https://www.microstrategy.com/Strategy/media/downloads/abou
t-us/microstrategy-bi-survey-13.pdf
https://www.whitehouse.gov/the-press-
office/2015/09/15/executive-order-using-behavioral-science-
insights-better-serve-american

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“To ensure we are addressing the critical differences in an
organization, we must pay attention
to both the national overlay and organizational narrative,
including the social, historic, and
political perspectives of those within the system. These shape
how people relate to one another,
even if all of the participants are of the same nationality or
home culture.”
Defining Diversity and Adapting
Inclusion Strategies on a Global Scale
Lessons from the Field, for the Field
By Judith H. Katz and
Frederick A. Miller
One of the foundational questions for the
field of Organization Development, and
for OD practitioners, is how to ensure our

work is seen and experienced as relevant
wherever we practice around the globe
and to ensure that individual training and
experience (in our case, as United States-
based practitioners) does not limit us from
effectively understanding and working in
other cultural contexts.
As a White woman and African-
American man born, raised, and educated
in the United States, we have had to navi-
gate our own identities as we have worked
both in the US and globally and adapt our
theory and practice of strategic culture
change to the cultural contexts in which
we work. This is even more critical as our
practice focuses on helping clients create
higher-performing, inclusive organiza-
tions that leverage differences to be more
effective in their interactions and in the
marketplace.
In this article, we will share what we
have learned from our work in organiza-
tions around the globe. This involves first
addressing the concern that “diversity”
itself is often thought of as a US concept
primarily related to race and gender. We
will address how we have been able to use
inclusion in a culturally-sensitive way as
a key to strategic culture change. With
that foundation, we will illustrate how we
have successfully adapted frameworks and
change models.
Diversity: A Concept to Translate

Foundational to the work on diversity
and inclusion has been the very concept
of diversity itself. In the US, conscious-
ness about diversity as something to be
unleashed in the workplace grew out of
the Civil Rights Movement and initially
focused on race and subsequently gen-
der. Over time, collective understanding
of diversity has grown to include other
underrepresented groups, and diversity
work in some organizations is now focused
on a wider range of differences, including
sexual orientation, gender identity, age,
religion, nationality, work style, and more.
In our work, we focus not only on
leveraging differences, but also on con-
scious inclusion, knowing that is important
to not only have differences in the work-
place, but to enable each individual to do
their best work. This means ensuring that
an organization’s culture and interactions
support individuals of all identities and
their different perspectives, backgrounds,
and experiences to contribute to enhance
problem solving and innovation.
Shifting from Diversity to “Differences
that Make a Difference”
No matter where we are in the world,
getting the right people in the room to do
the right work is critical to organizational
success. This means working with the
organization to think about how best to
ensure people at all levels of the organiza-

tion and of all backgrounds can contribute.
The challenge is to understand and find
out which differences make a difference
within that country or region and how
those differences play out within that orga-
nization (Miller & Katz, 2013a). Figure 1,
above, refers to some of the differences that
seem to make the biggest difference in how
people are included—or not—in an orga-
nizational culture. This model provides an
opportunity for people in the client system
to consider and discuss which differences
are being joined with or judged the most,
thereby having the greatest impact on inter-
actions and performance.
When working with clients outside
the United States, we often encounter
concerns that we will put a US lens on our
work related to differences, specifically, a
focus on race and gender. Our identities
have also led some clients to believe we
will focus on these issues. Of course, this
speaks to the assumptions and frames
many bring about the US and our iden-
tities, all of which need to be worked
through, either directly or indirectly.
Using the “differences that make a
difference” framework when entering the

system allows us to begin with a larger
conversation with the client about differ-
ence as we work together to identify which
differences are most important within their
organization and country. We have found
that the reality of differences is universal—
every society has some groups that hold
more power than others and some history
of oppression. As we engage within orga-
nizations, we also hear about the pain and
barriers individuals and groups experience
due to a variety of differences in addition to
social identify, such as function and level.
Finding out early on what differences
make a difference through these conversa-
tions with people at all levels in the organi-
zation, understanding the cultural context
and organizational challenges, and using
our own skills of observation has proven
critical to our success in client systems
globally and has enabled us to effectively
address the differences that create chal-
lenges to higher individual, team, and
organization performance.
For instance, as part of a change effort
in a Mexico City plant, we used Conscious
Actions for Inclusion (Katz & Miller,
1995/2016) (see Figure 2, next page), a
model that is a foundational part of our
practice, for creating common language
across the organization and providing
a common set of behaviors that were
expected of each individual. Seeing the
model for the first time, senior leaders

claimed that focusing on the behaviors
was unnecessary because the culture was
already inclusive. The leaders indicated
how they always greeted people and that
they indeed had a “warm” culture. How-
ever, interviews with members of the orga-
nization clarified that while people were
outwardly very friendly to one another—
certainly more so than we might experience
in some U.S. organizations—the leaders
were not treating everyone equitably. Lead-
ers would say hello to everyone, but gender
and level in the organization determined
who got the most opportunity to share
their perspectives in conversations and
meetings. Many people said that they did
not feel safe speaking up to leaders, which
led them to hold back ideas for improve-
ment. When we shared these observations
with leaders, they realized they indeed had
work to do to create an environment where
people felt they were listened to and it was
safe to speak up to solve problems.
Gaining Context with
One Up and One Down
To ensure we are addressing the critical
differences in an organization, we must
pay attention to both the national overlay
and organizational narrative, including
the social, historic, and political perspec-
tives of those within the system. These
shape how people relate to one another,
Figure 1. Judging or Joining: It Makes a Difference

© 1992–2012 The Kaleel Jamison Consulting Group, Inc. All
rights reserved. No duplication permitted without
written consent. 518 271-7000. www.kjcg.com. Adapted with
permission from the work of Bailey Jackson, Ed.D.
43Defining Diversity and Adapting Inclusion Strategies on a
Global Scale: Lessons from the Field, for the Field
www.kjcg.com
even if all of the participants are of the
same nationality or home culture. We know
from research that prejudices exist (Allport,
1954) and we all carry implicit and uncon-
scious bias (Ross, 2014), so the question
becomes, in what ways are these showing
up within the organization?
These dynamics were clear in an
engagement we undertook with leaders
of the Europe, Middle East, and Africa
(EMEA) division of a large, multinational
company. The focus of the work was leader-
ship team alignment and creating a clear
strategy for moving the region forward.
The group of 50 leaders included members
from countries throughout that vast EMEA
geography. Early on, it was clear to us that
the leaders from countries in Europe inter-
acted with leaders from African countries
in ways that reinforced one-up and one-
down dimensions. Similarly, there were
jokes and stereotypes expressed among the

European leaders about their colleagues
from other European countries. While not
naming that some of their challenges were
due to “diversity” issues, our work needed
to help them find new ways of interacting
and addressing the biases that were actu-
ally holding their performance back due
to a lack of trust and collaboration. Our
work in creating alignment incorporated
looking at the assumptions that people
were making based on their worldview and
breaking through some of the judgments
that were being made as people had dif-
ferent styles and approaches to achieving
their agreed-upon outcomes. As the group
worked toward creating alignment of their
goals and objectives, it was equally impor-
tant to achieve alignment on their need
to interact in more joining ways (Katz &
Miller, 2013b).
Knowing there is a different worldview
of barriers and challenges based on the
experience of being one-up and one-down
also helps drive strategies for change. For
instance, when we first started working
in Singapore in 1987, many Singaporeans
believed theirs was a very diverse and
inclusive country. However, it was clear
that, despite these values, there was a peck-
ing order within our client organization in
which the Chinese held the most senior
positions, people of Indian descent were
next most senior, and Malaysians were
most junior. Understanding these dynam-

ics was critical to the success of our work
and to the organization’s commitment to
becoming more inclusive.
Laying the Groundwork for
Conscious Inclusion Work
Creating a Safe Container for
Working with Difference
Following understanding of the context and
the ways in which differences are playing
out, our next critical task is to intervene
in a way that creates the container for the
work we are going to do in a system. Our
charge is to create a safe space and to gar-
ner the trust needed so people in the client
system believe that, as consultants from
another culture, we can support them in
their work (Katz & Miller, 1995/2016).
As we start our engagement with cli-
ents, we know it is critical to meet face-to-
face as soon as possible. Often, that is not
an initial option, so we ensure that we meet
via videoconference so we can see non-ver-
bal signals and begin to establish both con-
nection and safety for the client and for us.
For many in high-context cultures, this type
of connection is a critical element to estab-
lishing trust and overcoming cross-cultural
hurdles (Hall, 1976; Hofstede, 2001).
Creating a safe container is founda-
tional in our entry into the system. Like
Figure 2. Conscious Actions for Inclusion

Copyright © 1995–2014. The Kaleel Jamison Consulting Group,
Inc. All rights reserved. No duplication permitted
without the written consent of The Kaleel Jamison Consulting
Group, Inc. 518 271-7000. www.kjcg.com.
www.kjcg.com
many OD consultants, informational
interviews enable us to meet with people
one-on-one or in small groups to under-
stand the challenges they and the organiza-
tion are facing and to shape our work and
specific interventions. Being effective in
listening is a culturally-aware practice that
cannot be overvalued.
Once on the ground, we strive to
spend enough time with people so that
they begin to know us and feel safe telling
us what is going on and what we need to
know to be successful. For instance, in
Singapore, the CEO and HR leader coached
us on mannerisms that came across as too
aggressive and helped us change how we
describe “straight talk” to a more culturally
appropriate “communicating clearly and
directly.” Positioning is critical, so we walk
around numerous times, seeing people
again and again in the canteen and in their
work spaces.

The process of getting to know
individuals and groups in a system also
provides an early forum in which people
can deal with any discomfort and voice
their concerns about working with US
consultants so that we can address their
concerns. During an engagement in the
Netherlands, many of those we met with
said there were issues among people,
but that these were not “diversity issues”
and that they were skeptical of a “US
diversity” project. By framing the work as
being focused on the outcome of inclu-
sion, people were much more open to
engaging and saw the value of the work
that we were going to undertake. Over the
years, we have found that, regardless of
culture, most people want to be included,
contribute, and have an environment in
which they can do their best work. Our
job working in any organization is to find
out what that means for the people of that
organization and co-create with the client
how to best make that happen. Framing
work around inclusion—the outcome of
leveraging differences—enables people to
lean in and see their self-interest in join-
ing the effort. Once people are clear that
inclusion is not just for inclusion’s sake,
but rather a core element of achieving
the organization’s mission, strategy, and
goals and enabling them to be successful,
people see the effort as having local and
personal importance.

Using Oneself
Critical to working globally—and—
domestically—is entering a system with
a clear awareness of our own culture and
our cultural and individual biases, both
conscious and unconscious (Katz & Miller,
2003). When working outside of our home
country, it is even more critical for us to
avoid entering a system with assumptions
about a common worldview and value sys-
tem. We each carry our own gender, racial,
national, professional identities, and other
backgrounds with us and continually seek
to understand the impact of our cultural
identities and experiences on our behav-
iors and how we appear to others. Really
understanding our own cultural baggage is
foundational to being able to hear, partner
with, and understand how others are both
similar and different.
Early on in our careers, we participated
in an interview process with a Singapor-
ean company for which we were flown to
London to meet with two executive leaders
and a local consultant. We came prepared
to share our models and approach, but
instead ended up spending the day talk-
ing about our values. We were surprised
that this potential client did not first want
to hear about what we would do; their
worldview was that if we were aligned on
values, the rest of the engagement could
be worked out in partnership and would be
successful. This was and continues to be
dramatically different from our experience

working with US companies.
The same client showed us again the
importance of being mindful of our own
biases when conducting a session with
the CEO and his leadership team of three.
As part of the session, we asked the team
to complete a survival-type activity in which
all team members were charged with com-
ing to consensus on the priority issues.
Teams we had worked with in the United
States often completed the task in about
45 minutes, but this team was still work-
ing on the task three hours later. One team
member held a very different point of view
about what the team needed and the rest
of the team held the position that the task
would not be complete until each team
member was “happy” with the outcome.
They approached other tasks similarly
throughout our engagement, providing
us with new insights about cultural differ-
ences in decision making and the true
meaning of consensus.
Inclusion as Strategic Culture Change
Our clients bring us in because they need
to achieve particular business objectives
that will be facilitated by making inclusion
critical to HOW they work. Just as engage-
ment is an organizational value around the
globe, inclusion is also an outcome organi-
zations strive for, regardless of geography.
The challenge for each organization is to

determine what inclusion looks like in light
of their particular business objectives.
We address the creation of inclusive
interactions as an element of culture
because it requires a comprehensive and
targeted systems approach, tailored to the
needs of the business, in which differences
and inclusion are a means to achieving
higher performance rather than ends unto
themselves. A total systems change effort
(Katz & Miller, 2016) is required to create a
major shift in what is valued, who is at the
table, how people interact, and how work
gets done. When inclusion is the common
language of the organization, people under-
stand one another more quickly and more
accurately. They have the sense of safety
needed to speak up, make problems visible,
and address problems quickly rather than
being afraid of being seen as the dissenting
voice or the bearer of bad news. As a result,
problem solving and decision making are
accelerated and waste is eliminated (Katz
& Miller, 2013a; 2009). Inclusion as a
cultural element can increase productiv-
ity, profitability, engagement, and a host of
other positive indicators in organizations.
However, achieving it requires transform-
ing systems—what we call an inclusion
breakthrough (Miller & Katz, 2002).
The common element of this
approach, regardless of where the work
takes place, is opening the door to con-
scious inclusion to enable higher per-

formance and sustain culture change.
Opening that door involves several steps:
» Selecting, educating, and supporting
a core group of internal change agents
who focus on accelerating culture
change through peer-to-peer interaction
and influence.
» Conducting organization-wide educa-
tion on the practice of consciously
inclusive behaviors to create common
language, develop skills, and leverage
difference across the organization.
» Implementing just-in-time coaching to
enable people to effectively and quickly
apply inclusive mindsets and behaviors
in their teams.
» Implementing tools that enable clear
communication and eliminate waste in
meetings and day-to-day interactions.
Sustaining culture change calls for
implementing a measurement tool to hold
people accountable for demonstrating
consciously inclusive behaviors, identify-
ing core business processes and metrics
that would improve to a significant degree
if greater inclusion existed, and revising

people policies to reflect inclusive values
and practices in selection, hiring, coach-
ing, development, performance reviews,
rewards/bonuses, and promotions.
Two engagements in Asia illustrate
how measurement sustains culture change
in our client organizations.
In a recent engagement in Singapore,
many of the leaders, who were expats, expe-
rienced the largely Singaporean workforce
as not speaking up in team meetings or
formal forums. One of the early steps in
the effort was to create a cohort of change
agents, a diverse group of 50 people from
across the plant. The pre-session interviews
we conducted with the potential partici-
pants featured very engaged conversations
and we observed that people were very
engaged with one another during session
breaks, yet when they came together as a
group, there was almost silence. We shared
our observations about the silence in the
room and one person remarked, “We have
a lot to say, but no one wants to listen.”
The reticence the largely expat senior
leadership team attributed to cultural
differences was actually due to an organi-
zational culture that made it difficult for
people to speak up and rarely listened to
those who did speak up. By creating space
to surface this information, consciously
changing the cultural norms, and creating

the cohort so people knew they would not
be speaking out alone, the group eventually
became very active in the change process,
shared their views more, and gave more
and more leadership to the plant. Members
of this early change agent group went on
to bring issues to leadership and work for
greater inclusion by ensuring their peers’
voices were heard and that issues that
impacted people’s ability to contribute to
organizational success were addressed.
People had lots of ideas for improvement,
but found that, when they spoke, others
often interrupted them, leading many to
feel that their contributions were unwel-
comed. A major part of the intervention
was working not only with the cohort, but
with the expats, teaching them skills to
foster greater inclusion and truly listen to
what people had to say. Once the environ-
ment shifted toward greater openness and
listening, plant performance improved dra-
matically. The change agent group was able
to extend their learnings to others through
peer-to-peer leadership and helped others
find their voices to share their ideas.
Another team of plant and functional
leaders from China, Japan, Indonesia, Sin-
gapore, and Australia (including Irish, UK,
and US expats), also faced the challenge of
team member reluctance to speak up. This
was exacerbated by the fact the team oper-
ated primarily in English, which was a sec-
ond or third language for many members
of the group. Conversations would happen

rapidly and in a Western cultural style,
which made it challenging for Asian team
members to speak up and be heard. Often,
when an Asian team member sharing an
idea paused to take a breath or a moment
to think, another team member would cut
her or him off. And, because of their chal-
lenges with English, the Asian leaders were
being judged as less effective, regardless of
their actual results, making them less likely
to move into positions of greater leader-
ship. While we had talked with each person
prior the session and heard great thinking,
much of the Asian members’ thinking
was not a part of the conversation once the
team assembled and interacted.
At dinner with this group after our
first day of work with them, Judith was
seated next to one of the plant leaders from
China. She was struck by how much the
woman had to say—her lively and robust
conversation was nothing like her behavior
in the group earlier in the day. On the sec-
ond day with the group, we decided to ask
each member to stand up when they talked,
allowing them to physically claim space in
the conversation, regardless of their facility
with English. Standing signaled that they
still had things to say, even if they paused
to think and mentally translate. This also
allowed them share their thinking without
being interrupted or having conversations
overlap. While standing initially seemed
awkward, the impact on the quality of work
and the ability to get everyone’s thinking

was immense as some members of the
team learned how much their colleagues
had to offer and others found a new pro-
cess for contributing.
Later, the team applied a similar pro-
cess in conference calls, with a new norm of
waiting two beats after someone shared her
or his thoughts and checking that they were
done speaking before someone else started
to speak. They came to realize that by slow-
ing down, they were in fact speeding up
their own process of problem- solving and
decision-making, which increased inclusion
and helped eliminate waste in their interac-
tions (Katz & Miller, 2010).
Adapting Approaches and Models
Effectively adapting organization develop-
ment approaches and models—both ours
and others’—to our client engagements
outside of the US has been essential to
facilitating the culture change and inclu-
sion breakthroughs that have impacted
our clients’ productivity and success. The
concepts we use are basically the same
globally, but how we implement our work
can vary dramatically based on national
and organizational contexts. By being able
to adapt, flex, and create new methodolo-
gies, we have been able to address concerns
about our ability as US consultants to be an
effective and adaptable partner.
Our experience has been that most

models and approaches can work globally
if they are properly translated into the cul-
tural context and are aligned with the goals
of the system and people’s self-interest.
They have to make sense to people—people
need to see some immediate advantage to
using new behaviors and changing how
they interact. “Making sense” often means
the proof is in seeing both short-term and
long-term success achieved.
Cultural Adaptation
Some examples of successful cultural adap-
tation we have found include the following.
In Japan, it was critical that members of a
client system did not feel we were advo-
cating they go against the cultural norm.
One of the key cultural dynamics we have
often heard in Japan is “the nail that sticks
out gets hammered.” This cultural saying
translates into a strong need for harmony
within a group or team, which often
makes people reluctant to raise issues that
might be problematic. Having worked in
Toyota in the US, we were familiar with a
major component of the Toyota Produc-
tion System that called for anyone on the
production line who saw a quality issue to
pull the “andon cord” and stop the line’s
operations. This experience helped us
bridge the gap and reframe speaking up

as a practice that creates greater harmony
by letting others know of an issue before
it becomes a big problem for the team.
This framing—for the good of the group—
made people more willing to raise issues
in the spirit of helping the team be better.
Similarly, we used the lean manufacturing
concept of eliminating production waste as
a framework for considering how inclusive
behaviors eliminate waste in human inter-
actions (Miller & Katz, 2013b).
Conclusions
Our experiences working with clients
around the globe continue to reinforce the
major tenets of OD, particularly the need to
constantly develop and grow ourselves as
instruments of change and the importance
of not only bringing our skills but also
shaping and co-creating strategy with our
clients. Working on differences that make a
difference in each organization (locally and
regionally) creates a space for the issues of
difference that matter in that system to be
identified and addressed. Adapting models
and frameworks for change so that they
are relevant to our client systems is not
only a need in working globally, it is the
very essence of OD work. Such adaptation
requires us to constantly adjust our own
attitudes, beliefs, and methodologies to the
local national, cultural, and organizational
circumstances. Our job as change agents
is to understand, adjust to, and challenge

the system and ourselves in the process.
In doing so, we are able to help our clients
achieve their ultimate goals while hewing
to the values that are central to our practice
and our field.
References
Allport, G.W. (1954). The nature of prejudice.
Reading, MA: Addison Wesley.
Hall, E.T. (1976). Beyond culture. New York,
NY: Random House.
Hofstede, G. H. (2001). Culture’s conse-
quences: Comparing values, behaviors,
institutions and organizations across
nations. Thousand Oaks, CA: Sage
Publications.
Katz, J. H., & Miller, F.A. (2003). Diversity
consultation skills. In D. Plummer
(Ed.), Handbook of diversity management:
Beyond awareness to competency based
learning (pp. 427–447). Lanham, MD:
University Press of America, Inc.
Katz, J. H. & Miller, F. A. (2008). Be BIG:
Step up, step out, be bold. San Francisco,
CA: Berrett-Koehler.
Katz, J. H., & Miller, F. A. (2010). The need
for speed: It starts with interaction.
Chief Learning Officer, 9(6), 34.
Katz, J. H., & Miller, F. A. (2013a). Open-

ing doors to teamwork and collaboration:
4 Keys that change everything. San Fran-
cisco, CA: Berrett-Koehler.
Katz, J. H. & Miller, F.A. (2013b) Judg-
ing others has not worked so let’s
join them. Executive Forum: Leader to
Leader, 70, 51–57.
Katz, J.H., & Miller, F.A. (1995/2016). Con-
scious actions for inclusion. Unpublished
manuscript.
Katz, J. H., & Miller, F.A. (2016). Leverag-
ing diversity and inclusion for perfor-
mance. In W. Rothwell, J. M. Stavros, &
R. Sullivan (Eds.). Practicing organiza-
tion development: Leading transformation
and change, 4th edition (pp. 366–375).
Hoboken, NJ: John Wiley & Sons.
Miller, F.A., & Katz, J. H. (2002). The inclu-
sion breakthrough: Unleashing the real
power of diversity. San Francisco, CA:
Berrett-Koehler.
Miller, F.A., & Katz, J. H. (2013a). If differ-
ences are to make a difference we need
an “inclusion breakthrough.” Retrieved
from www.diversitycentral.com/tools_
and_resources/featurearticle.php.
Miller, F.A., & Katz, J. H. (2013b). Eliminat-
ing waste through global standard work for
interactions. Unpublished manuscript.

Ross, H.J. (2014). Everyday bias: Identifying
and navigating unconscious judgments in
our daily lives. Lanham, MD: Rowman &
Littlefield.
Judith H. Katz and Frederick A.
Miller, thought leaders in organi-
zation development for more than
40 years, have created numerous
breakthrough concepts in their
field, including Inclusion as the
HOW® as a foundational mindset
for higher operational perfor-
mance and accelerated results.
As Executive Vice President and
CEO (respectively) of The Kaleel
Jamison Consulting Group, Inc.—
one of Consulting Magazine’s
Seven Small Jewels in 2010—they
have partnered with Fortune 50
companies around the globe to
elevate the quality of interactions,
leverage people’s differences, and
transform workplaces. Both recipi-
ents of the OD Network’s Lifetime
Achievement Award, they have co-
authored several books, including
Opening Doors to Teamwork and
Collaboration: 4 Keys that Change
EVERYTHING (Berrett-Koehler,
2013). Katz can be reached at
[email protected] Miller can
be reached at [email protected]

www.diversitycentral.com/tools_and_resources/featurearticle.ph
p
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By Allan H. Church
“Historically, the evaluation component of the classic
consulting model has largely been downplayed or ignored.
Today,
with increasing pressure from organizations to demonstrate the
value of our efforts, having both a well-designed and
articulated evaluation strategy is key, as is a detailed multi-
measure and level measurement process.”
The Art and Science of Evaluating
Organization Development
Interventions
How do we evaluate the impact of our
organization change programs, processes,

and initiatives? What are the best ways
to measure success or failure of various
interventions? How do we know we have
really made a difference? While the field of
organization development (OD) has its ori-
gins in action research and enhancing the
growth and development of organizations
and their people, if we are honest with
ourselves, our focus as a field on formally
evaluating the impact of our work has
lagged far behind. The level of emphasis
collectively placed as a field on the debate
around having a clear and consistent
definition of OD, the right set of core OD
values, and creating new types of tools and
techniques has far overshadowed the rigor
and share of mind given to measuring the
impact of our efforts.
Why is this the case? Is this due
to practitioners’ lack of measurement
design and analytics capability as some
have argued (e.g., Church & Dutta, 2013)?
Recent research conducted on over 380
practitioners in the field (Shull, Church,
& Burke, 2014) would suggest this might
be part of the issue. Only 29% cited using
statistics and research methods in their
OD toolkit. Or is it because it is not part
of their values structure? That same study
reported that evidence-based practice was
ranked 21st out of 34 possible values that
drive their efforts. The history of evaluation
as a core practice area in OD would also
support this argument. Could the reason
for our lack of focus on outcomes simply

be because it’s too difficult and daunting
to design a meaningful and robust evalu-
ation process?
Whether you are an external consul-
tant or internal practitioner there are a host
of challenges associated with the measure-
ment of causal relationships resulting from
organizational interventions at the individ-
ual or systems level. Despite the definitive
writings of Kirkpatrick (1998), the prospect
of evaluating much of what we do in the
social sciences and in organizational set-
tings involves dynamic, interdependent,
and often long-lead times that can far
outlast the consultant-client (or employee-
employer) relationship. In fact, one of the
most frustrating elements of being an
external practitioner is the lack of visibility
to the long-term impact of one’s work. This
is often cited as a key reason why people
take internal positions. While it’s fantastic
to experience multiple client organizations
and challenges, it can also be quite reward-
ing to experience first-hand the changes
in a company (or other social system)
following work you have personally had a
hand in over time. The alternate side of the
equation are the personal challenges and
even threat to evaluating one’s own work.
As an external consultant, if your project
fails to deliver you might not get paid for
that engagement. As an internal practi-
tioner, your program or process might be
cancelled and you could find yourself out

of a job.
All of this sits squarely in juxtaposition
with the client’s interest in measuring the
impact and in some cases financial return
on investment (ROI) of our interventions.
While this element of the work has always
been present (arguably few paid organiza-
tional interventions are done purely for the
sake of humanistic values alone), in today’s
hypercompetitive business environment
the emphasis has never been stronger.
Given the dynamics and challenges cited
above (e.g., capability, values, complexity,
and personal interest in the game) how do
we as OD practitioners move the needle
and more holistically embrace the evalua-
tion conundrum in our efforts?
The purpose of this paper is to discuss
this issue in depth and attempt to answer
these questions by focusing on the art
and science involved in evaluating OD
interventions. The paper begins with
a brief overview of the evolution of the
evaluation phase of the classic consult-
ing paradigm from an afterthought to a
core element required in the field today.
This will be followed by a discussion of
three key requirements for setting an
evaluation strategy. Lack of attention to

these areas works against practitioners
and their clients’ ability to appropriately
conceptualize and implement suitable
outcome measures. These requirements
will be presented in the context of why they
cause issues and how best to address them
up-front in the process. The paper then
offers three additional recommendations
for creating an effective evaluation process
that will yield the right kinds of informa-
tion needed to demonstrate the impact
of OD and related applied organizational
interventions.
Recognizing Our Biases
Before proceeding, however, and as any
OD practitioner should do, it is important
to recognize several biases inherent in
the approach to be presented here. First,
the perspective is from that of an organi-
zational psychologist by formal training
with a significant grounding in applied
statistics and measurement theory (and
therefore represents a scientist-practitioner
mindset). Thus, there is an inherent bias
that evaluation methods for all types of
organizational initiatives (whether directed
at organization change, enhancing develop-
ment, or improving performance) should
follow some degree of rigor and contain
both quantitative as well as qualitative
components of OD as a data-driven process
(Waclawski & Church, 2002).

Second, the insights and observations
offered are based on the author’s personal
external and internal consulting experience
and evaluation research over the past 25
years following the implementation of a
variety of large-scale organizational change
initiatives and global talent management
processes. The focus therefore is less on
one-off individual coaching engagements,
team building efforts, or group interven-
tions but more on measuring the impact of
broader initiatives, systems, and processes.
Thus, while the suggestions offered reflect
a certain normative and science-based
paradigm, and are constrained by the expe-
riences of the author, it is hoped that they
will appeal to a much broader spectrum of
OD applications.
The Evolution of Evaluation in OD
Although the evaluation stage of the clas-
sic consulting model that OD shares with
many other applied social science disci-
plines, such as industrial-organizational
psychology (I-O) and human resource
development (HRD), has been present
since Burke (1982), Nadler, (1977), and
others (e.g., Rothwell, Sullivan, & McClean,
1995) discussed the framework, the
focus continues to be relatively limited
in the field.
As many authors have noted (e.g.,
Anderson, 2012; Burke, 2011; Church,

2003; Cummings & Worley, 2015), the
evaluation stage in the model is often given
lip service or overlooked entirely. This is
true whether you look at classic approaches
to doing OD work as well as the newest
dialogic approaches (Bushe & Marshak,
2015—where evaluation, for example,
is not even listed in the topic index). A
quick scan of the EBSCO database shows
no academic articles published at all, for
example, on the terms evaluation and OD
since 2012.
Instead, the emphasis has often been
placed on the actions taken or the change
in behaviors and culture observed. While
some research on the evaluation of various
individual OD methods has certainly been
done (e.g., Basu & Das, 2000; Terpstra,
1981; Woodman & Wayne, 1985), and there
is a plethora of qualitative and quantitative
case studies both individually and in OD
texts citing the impact of various programs,
relatively few authors have taken a more
focused view of how to systematically
measure our efforts. Moreover, many of
these have come from authors with cross-
disciplinary backgrounds (e.g., Armenakis,
Bedeian, & Pond, 1983; Edwards, Scott, &
Raju, 2003; Martineau & Preskill, 2002;
Figure 1. Classic OD Consulting Process Model
Contracting
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