This document discusses several change stories from companies like Hewlett-Packard, McDonald's, and Kodak. It analyzes mistakes made in each change process, such as making major changes too quickly (HP) or failing to communicate changes effectively to employees (Kodak). The document recommends strategies that could have improved each change process, such as setting short-term goals (HP) or gathering employee feedback earlier (McDonald's). It also discusses frameworks for managing organizational change and evaluating the effectiveness of different change management strategies.

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Title of Paper
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HCA375– Continuous Quality Monitoring and Accreditation
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HCA375 - WEEK 4 ASSIGNMENT
PART 1 – DESCRIPTION OF ADVERSE EVENT
Refer to the instructions in the Week 4 Assignment of your
online course to understand what is expected in each column.
This completed template should be between six to seven pages
in length. Include APA citations within the description column
where appropriate. List your references in APA format
according to the Ashford Writing Center guidelines on the last
page of this template.
CONTENT
DESCRIPTION
ADVERSE EVENT CHOSEN
DESCRIBE THE EVENT

2. WHO WAS INVOLVED IN THE EVENT (Health care
Personnel)
COMMUNICATION TECHNIQUES/METHODS UTILIZED TO
RESOLVE THE PROBLEM
OPERATIONAL OR SAFETY PROCESSES RECOMMENDED
TO AVOID FUTURE EVENTS FROM HAPPENING. LIST AT
LEAST 2.
HISTORICAL, CONTEMPORARY, AND LEGAL
INFORMATION ABOUT THE EVENT CHOSEN
APPLYING CONTINUOUS QUALITY MONITORING -
STATE THE IMPACT OF THIS EVENT FROM THE
ORGANIZATION’S AND PATIENT PERSPECTIVE
WEEK 4 ASSIGNMENT
PART 2 – CQI TOOL
Choose a CQI Tool that best suits your chosen Adverse Event
from this list of three:
· Flowchart
· Fishbone Diagram (Cause & Effect)
· Pareto
Use the CQI Tool to illustrate the use of the tool with your
chosen Adverse Event. You will be responsible for creating the
CQI Tool, completing the tool, taking a screenshot, and
copying/pasting the screenshot into the space below.
WEEK 4 ASSIGNMENT
PART 3 - FUTURE PREVENTION

3. APPLYING PDSA - Worksheet
PHASE
PHASE ACTIVITIES
EXPLANATION
PLAN
Identify the problem.
What is your objective?
Identify the team members that will work on the problem.
How would you communicate the plan to the stakeholders?
What data are you collecting?
Whom are you piloting your plan on? (You need to select a
small group to pilot your plan on before you implement fully).
DO
Develop possible solutions to the problem.
Select one of the possible solutions to implement in this pilot
phase.
What was the result of the pilot?
Detail the method(s) utilized to communicate the improvement
process.
List observations and note any problems.
STUDY
Summarize the data collected and measure if the pilot solution
was effective. Identify any issues that occurred. Include any
communication issues.
Compare your objective in the Plan phase to that of the actual
pilot result.

4. Revise plan if needed – describe.
ACT
Implement the plan for improvement. Describe how you will be
continually monitoring for the improvement plan’s sustained
success.
References
Excluding your textbook or course readings include a minimum
of four scholarly, peer-reviewed sources; two of which must be
from the Ashford University Library that were published within
the past five years. All references must be in APA format
according to the Ashford Writing Center.
Stories of Change
Title:
Course Name:
Topic Name:
Professor’s Name:
Student Name:
Date:
Introduction
Change is a structured, cyclic, and complete approach for
transitioning organizations, individuals, and groups from a
recent state to a future state with future business benefits. For

5. any organization change management gives effective solutions
that must need to address changes due to compliance,
expansion, reforming, regulatory, mergers, and acquisitions
among other things (J P Kottert, 2007). In present time there
can be so many reasons for change is essential for an
organization including opportunity, high technology, customer
needs, financial wealth, and globalization. Today, organizations
must have the ability to adapt rapidly and effectively in order to
stay alive. So, employees and leaders of the organization must
know about the nature of the changes required and the likely
results of different approaches to bring about that change (J P
Kottert, 2007).
Using Kotter’s Model, Identify the Three (3) Most Significant
Errors Made Out of All of the Change Stories Presented and
Describe the Ramifications of Those Mistakes.
Any business organization that needs to develop and stay long
of the competition market should accept change. When an
organization determine to make a effective change there are so
many points that can go immoral. Opposition from employees is
one of the factors that play a significant part in a failure process
of organizations. The process of change must be actually
managed in an attempt to reduce the chance of confrontation (J
P Kottert, 2007). In all of the changes there are three most
important errors presented come about with Hewlett-Packard,
McDonald, and Kodak, first let’s look at Hewlett-Packard.
Carly Fiorina in the year 1999 became the new Chief Executive
Officer. In this time the company Hewlett-Packard had many
issues in many sections and lacked right direction. The main
aim of Fiorina’s was to rearrange the organization so that good
effective ideas were flow as they had been in the previous time.
In the year 2002 the company merged with Compaq Computer
Corp (CCP). The main mistake of the company was making
major or desperate changes (J P Kotler, 2007). The change story
of Kodak’s present during the change time how important
communication with its employees. Main change is mostly not

6. possible unless most of the employees are ready to help,
repeatedly to the point of making interim forfeit. But most of
the people will not make forfeit, yet if they are miserable with
the type quo, except they feel the possible benefits of change
are delightful and unless they truly feel that a alternation is
possible” (Gupta S, 2001). In the year 2003 Kodak determines
to stop production of camera those are traditional. This option
intended there would have to be a consolidation of reduction
and operations in employees. This type of changes did not move
over well with inside and outside stakeholders. Company’s
employees did not observe the point of interim sacrifice because
they did not think their valuable jobs would be protected. Kodak
had been persuasive when communicating the changes; the
employees may have sense improved about the alternation
(Gupta S, 2001).
A title of a documentary “Super Size Me” mostly helped the
company McDonald’s to understand that things were going
easily, the business company want to make some changes. The
financial documentary demonstrate that how obesity leads by
the consuming fast food. The company may not observe the
change must be needed because they think their troubles are not
that bad (Gupta S, 2001). They also refute that their food
products were harmful and easily ignored those who claim it
was. The title documentary forced the company to understand
that they had to be socially responsible business organization
and make the right product by providing better or improved
menu choices (Gupta S, 2001).
Make at Least One (1) Recommendation for Each Change Story
that Would Have Improved the Effectiveness of the Change
Process and Explain Why That Recommendation Would Have
Altered the Outcome of the Change Process.
Once again, the company Hewlett- Packard’s fault was making
radical changes. It is most excellent to make short-term wins
according to Kotter’s model. Transformations take some time
and it should not be quick. What Fiorina must have done was to
place instant goals so that company’s employees could see the

7. different changes were really producing better results. Setting
of instant goals would have permissible the company to have
measurable goals. This particular goals support you to persist
setting goals because it give wisdom of accomplishment
(Schermerhorn John R, 2011).
IBM Company’s main problem was they did not receive full
benefit of the use of the internet technology to develop and
grow their business. IBM lacked modernization needed to stay
alive of the competition market. A good recommendation would
have been for the corporate company to revamp their valuable
reward system. For a company a reward system would assist to
ensure the companies employees who were do better work and
coming up with innovative, those things would advantage from
their good efforts. (Schermerhorn John R, 2011).
Kodak Company could have made communicated its main vision
more openly to employees. Generally vision is communicated
most successfully when many special vehicles are used i.e
posters, large group meetings, openly one-on-one talks, memos,
and newspapers. When the equal message move towards people
from six special directions, it set a good chance of being
remembered and heard, on both logical and touching levels
(Schermerhorn John R, 2011).
When it moves to change story of McDonald’s, the fast food
company could go to workers to observe where they required
making some changes. Most important internal change rarely
occurs unless employees support. By receiving the views of
workers, McDonald would have understood that there were
some good areas that they required to change.
Explanation as to Why That Change Image Label is
Appropriate.
In present time companies Managers or CEO must achieve some
useful skills must be needed to communicate the process of
change to their employees in a specific way that give
confidence their loyalty to the process of change. In change
process communicating to employees should be made attentive

8. of what will be needed from them and to have a thoughtful of
really what will be taking place (Schermerhorn John R, 2011).
In Hewlett-Packard Carly Fiorina’s impression of organization
change after the joining. She must understand that there were
some workers had struggled to change. She guarantees these
particular employees understood the specific change by
conversing and interacting with them. The picture of nurturer is
related to a mother’s link with her child. The nurturer
understands changes are not unsurprising so they improve the
employee’s behavior or effort to nurture (Schermerhorn John R,
2011).
The image of David Grossman of IBM is that he implementing
some change was predictor. The role of predictor’s is to assist
develop a considerate of what is the means of change and how it
will assisting the company to better perform in the future
(Schermerhorn John R, 2011).
David Carp the CEO of Kodak used the director managing
change. The company’s director must designs the process of
change. Then the director led the employees to obey to company
so their main objective will be realized (Schermerhorn John R,
2011).
The image of James Cantalupo of McDonalds Company used
navigator of managing change. He used the devises of navigator
in change process so that it well fits the situations McDonald is
facing. The navigator knows that there some requirement to be
other areas changes along with some way and the closing result
may not be as designed (Schermerhorn John R, 2011).
Recommend a Different Strategy for Managing Change in Each
One of the Change Stories Presented and Provide a Justification
for Your Recommended Strategy.
For managing change a special strategy for Carly Fiorina would
be that of a trainer. A trainer finds innovative ways to ensure
changes are made. The trainer relies upon structure in the
correct set of drills, values, and skills that are think to be the
most excellent ones the members of organization will be
capable to illustrate on proficiently in order to get desired

9. organizational products (Aiken C & Keller S, 2009). As a
navigator David Grossman could have used the role. David
Grossman would have managed the company’s situation but he
would have been attentive that the outcomes may have been
frequently developing and could not be completely designed
because of some different influences and manners. The job of
manager is one of control, though the skill for the manager to
execute control can be reduced by the forces of internal and
external. This is a good and valuable change managing process
of David Carp that he has used (Aiken C & Keller S, 2009).
James Cantalupo mostly used the policy or strategy of
interpreter. The role of interpreter is to provide workers
suitable explanations as to why the specific change is taking
place. Through storytelling a skilled and good interpreter will
help the employees for see the big image. In change process
storytelling allows workers to find out mistakes from past while
for future success painting a picture (Aiken C & Keller S,
2009).
Conclusion
In organization changes are essential to allow the organization
to meet the challenges and demands for the internal and external
environment (Emily Denitto, 1998). The implementation of
successful organizational change lies on the skills of leaders to
identify the requirement for planned changes and the making of
strategic planning to make sure that both the workforce and
management integrate and communicate their endeavor or
efforts regarding the reaching of the organizational main goals
and encounter the demands of the vigorous environment of
internal and external. Changes in organization allows to setup
tactics and techniques to ensure the successful business of the
organization.
References
Kotter, J.P. (2007). Leading Change: Why Transformation
Efforts Fail. Harvard Business Review OnPoint (March-April)
1-10.

10. Gupta, S. (2001) Leading innovation change-the Kotter way.
International Journal of Innovation Science 3: 141-149
Schermerhorn,, J.(2011) Organizational Behavior, 12th Edition.
John Wiley & Sons.
Aiken C., Keller S. (2009) The irrational side of change
management. The McKinsey Quarterly
Emily Denitto, “New Steps Bring Alvin Ailey into the Business
of Art,” Crain’s New York Business, December 7, 1998, pp. 4,
33.