Practice Evaluation
The success of the International Classification of Functioning, Disability and
Health (ICF) depends on its implementation in practice. This article describes
an evaluation of the introduction of the ICF framework into an occupational
therapy service. Reflections from the working party responsible for its
introduction were related to change management theory. The experiences
throughout the implementation project could be mapped to an eight-stage
process of creating major change (Kotter 1996). The working party concluded
that the explicit use of and closer adherence to change management theory
could enhance the uptake of the ICF in clinical practice. Further exploratory
research is required to support these reflections

Appleby, H

English

Brunel University Research Archive

1British Journal of Occupational Therapy October 2006 69(10)IntroductionThe International Classification ofFunctioning, Disability and Health (ICF)The ICF is a framework and classification endorsed by theWorld Health Organisation and aims to provide a commonlanguage for use within the multidisciplinary team (WHO2001). The common language can also help to describethe clinical reasoning behind an intervention (Tempestand McIntyre 2006).This article does not seek to describe the ICF becauseprevious articles have explained the framework andclassification (Steiner et al 2002, Rentsch et al 2003). The College of Occupational Therapists (COT 2004) and the World Health Organisation both offer guidelines(http://www3.who.int/icf/icftemplate.cfm).Research has evaluated the use of the ICF withinrehabilitation and concludes that it improves the qualityof intervention and the multidisciplinary team process byproviding a systematic basis for team communication(Stucki et al 2002). The literature does not describe theimplementation process, yet the success of the ICF dependson the uptake within clinical practice (Geyh 2004). It is also recognised that introducing a new frameworkinto a service involves significant change and thatstrategies should be employed to improve the changeprocess (Kotter 1996).Change managementChange can be described as the process of moving from onesystem to another (Parsley and Corrigan 1994) and can becomplex, especially where attitudinal and behaviouralchanges are required (Goodwyn 1996). People differ intheir response to change and resistance can be attributedto four common factors: parochial self-interest (seeking toprotect the status quo), misunderstanding and lack oftrust, contradictory assessments and low tolerance forchange (Bedeian 2004).There is criticism of the amount of change within thehealth system and some believe that change has becomethe only constant (Managan 1996). Some commentatorsconsider that change is part of a chain of events and canonly be implemented during a period of stability(Goodwyn 1996, Managan 1996). However, this view has been challenged because periods of stability rarelyoccur. Instead, it has been suggested that embracingchange as a continuous process will have a positive effecton implementing change, rather than waiting for a period of stability (Sauser and Sauser 2002).There are conflicting views on who can implementchange within a service. Some believe that change hasbecome a central management issue, and that an effectivechange agent is someone with a broad and well-developedrange of qualities and skills, in an influential position(Buchanan and Huczynski 2004). However, irrespective Practice EvaluationThe success of the International Classification of Functioning, Disability andHealth (ICF) depends on its implementation in practice. This article describes an evaluation of the introduction of the ICF framework into an occupationaltherapy service. Reflections from the working party responsible for itsintroduction were related to change management theory. The experiencesthroughout the implementation project could be mapped to an eight-stageprocess of creating major change (Kotter 1996). The working party concludedthat the explicit use of and closer adherence to change management theorycould enhance the uptake of the ICF in clinical practice. Further exploratoryresearch is required to support these reflections.Using Change Management Theory toImplement the International Classificationof Functioning, Disability and Health (ICF) in Clinical PracticeHeather Appleby and Stephanie Tempest2 British Journal of Occupational Therapy October 2006 69(10)of their position within the team, individuals assumedifferent roles during the change process, includingcatalyst, process helper, solution giver and resource linker.These individuals aid the process by enhancing ownershipof change, forging honest relationships and setting goalsand action plans (Goodwyn 1996).For change to be successful, there must be a change inthe organisational culture and there are three factors thatmust be addressed: the evidence for change, the context inwhich change is being introduced and how the changewill be facilitated (Rycroft-Malone et al 2002). Introducing the ICF framework into anoccupational therapy serviceUntil 2002, the occupational therapy department in ateaching hospital in London was using the InternationalClassification of Impairments, Disabilities and Handicaps(ICIDH; WHO 1980) as the framework for service delivery.This had been adopted to facilitate multidisciplinary teamworking and to communicate the clinical reasoning foroccupational therapy intervention.Difficulties were encountered using the ICIDH, however,because it did not describe the contextual factors affectingan individual’s functional performance. The frameworkfelt incongruent with the holistic perspective of healthand, therefore, it did not allow therapists to demonstratetheir clinical reasoning. At that time, the WHO revised theICIDH and endorsed the International Classification ofFunctioning, Disability and Health (ICF) as its replacement.There was emerging evidence for the use of the ICF inclinical practice (Stucki et al 2002, COT 2004) and thiswas chosen as the new framework for service delivery.A working party of senior occupational therapists wasformed in May 2002 including both authors. The aim of theworking party was to introduce the ICF as the frameworkfor service delivery and this was achieved by December 2003.A variety of methods was adopted to aid implementation,including teaching sessions, the development of resourceson the ICF and altering documentation to use the newterminology. The process of implementation was notwithout challenges and the working party reflected on theexperience in order to share the journey and to learn forfuture service changes. Near the end of the project, the first author completeda Diploma in Management and explored change managementtheory within the course. Therefore, some of the theory wasused to guide the reflections from the working party.Process of reflectionThe reflections were gathered from the working party and mapped onto the concepts within the changemanagement theory by the authors. Opinion was gatheredas part of practice evaluation and service development,therefore formal ethical approval was not required at thetime of collecting data. However, as a result of theintention to publish, permission was subsequently soughtfrom and granted by the occupational therapy service toshare the experiences. The experiences throughout the implementationproject could be mapped to an eight-stage process ofcreating major change (Kotter 1996). The working partyconcluded that explicit use of and closer adherence tochange management theory could enhance the uptake ofthe ICF in clinical practice.DiscussionAn eight-stage process has been identified to create majorchange (Table 1). If successful change is to take place, it isvital that barriers are addressed proactively. It is recommendedthat the process is implemented in sequence for change tobe managed successfully (Kotter 1996).The discussion has been structured using these headingsto share the experiences during the implementation processat individual stages.Evidence and establishing a sense ofurgencyThe initial driver for change was a general sense offrustration within the occupational therapy team at thechallenges in communicating their role within themultidisciplinary team. The working party was able todraw upon this to support the need for change.In addition, there were difficulties in using the ICIDH,largely due to the negative terminology and the lack ofcontextual factors. The emerging evidence using the ICFsupported the need for change and information wassought from the WHO (2001) and COT (2004). Creating the guiding coalitionDiscussions initially occurred informally, until the decisionwas taken to form a working party. The guiding coalition(the working party) had a shared concern regarding thelack of clinical reasoning demonstrated in the currentdocumentation. As senior members of the occupationaltherapy team, the working party had authority within theservice, a prerequisite to implementing change successfully(Kotter 1996). However, the team later reflected that amix of staff would have been beneficial to enable theworking party to appear less hierarchical.Context and Developing a vision andstrategyThe working party devised a strategy to implement theICF by altering the documentation to include the ICFterminology. In order to do this, the occupational therapyteam needed information and education on the ICFframework and its use in clinical practice.The occupational therapy team works within a contextwhere change is normal, therefore the working partyanticipated that changes would be accepted. However, atthis stage the working party deviated from the eight-stageprocess for creating major change, resulting in conflict.3British Journal of Occupational Therapy October 2006 69(10)The vision was to improve the clinical reasoning withinthe documentation using the ICF. However, the conceptwas not fully embraced or understood by the wider teamin the early stages. On reflection, the working party shouldhave made a distinction between wanting to improve thestandard of documentation within the team and adoptinga new framework. The ICF should have been introducedas the framework for service delivery, with the benefits ofaiding clinical reasoning. Any necessary changes to thedocumentation to demonstrate the enhanced clinicalreasoning would have followed. The working partytherefore reflected that the initial vision required furtherdevelopment and had been communicated too early.Leadership and communicating the visionand strategyThe consequence of a lack of clarity for the vision meantdifficulties in communicating the vision. However, theworking party was prepared to admit that it was learningitself and this aided the development of a discussionculture to resolve conflict. The working party clarified the new vision, that is, to implement the ICF as theframework for service delivery, thus overcoming theresistance felt by some staff. Team members whodemonstrated support for the changes, for example, theprocess helpers and solution givers, were encouraged toparticipate in leading the developments, thus promotingchange at the grass-roots level.On reflection, the working party felt that the use of theeight-stage change management process would have beenbeneficial. By using the staged approach, it would havebeen evident that stages three and four were not followedsequentially, resulting in confusion and conflict. Facilitation and empowering broad-basedactionAn interactive facilitation style was adopted, includingsmall-group activities, reflection during supervision andinformal discussions. Case studies were used to mapinformation to relevant headings within the ICF anddiscussions were facilitated to identify how this aidedclinical reasoning. This enabled the occupationaltherapists to analyse, reflect and change their attitudes and practice. The small teams were encouraged to sharechallenges and successes, using the framework to promote further learning and development.Generating short-term winsShort-term objectives were established for implementationand the ICF terminology was introduced into the initialpart of the documentation. Staff were encouraged toreflect on their progress in small teams for a period of 4 months. Feedback during this period demonstrated aheightened appreciation of the limitations of the previousdocumentation and the advantages of using the ICF tostructure the new documentation and communicateclinical reasoning. Staff also used the framework to aid the developmentof clinical reasoning with new staff and students. Studentson fieldwork placement were learning the ICF within theirdegree course and this helped to maintain motivation forthe therapists in practice because they realised thecurrency of the changes.Evaluation, consolidating gains andproducing more changeChange was introduced gradually over 2 years and alldocumentation now incorporates the ICF terminology. TheICF is the framework for service delivery and has aidedclinical reasoning, although continuing training is requiredto cement the changes. The documentation is reviewedregularly as part of ongoing service development.Table 1. The Eight-Stage Process of Creating Major Change(Kotter 1996)*1. Establishing a sense of urgency■ Examining the market and competitive realities■ Identifying and discussing the crises, potential crises, or majoropportunities2. Creating the guiding coalition■ Putting together a group with enough power to lead change■ Getting the group to work together like a team3. Developing a vision and strategy■ Creating a vision to help direct the change effort■ Developing strategies for achieving that vision4. Communicating the change vision■ Using every vehicle possible to constantly communicate the newvision and strategies■ Having the guiding coalition role model the behaviour expected ofemployees5. Empowering broad-based action■ Getting rid of obstacles■ Changing systems or structures that undermine the change vision■ Encouraging risk taking and non-traditional ideas, activities and actions6. Generating short-term wins■ Planning for visible improvements in performance, or ‘wins’■ Creating those wins■ Visibly recognising and rewarding people who made the wins possible7. Consolidating gains and producing more change■ Using increased credibility to change all systems, structures andpolicies that don’t fit together and don’t fit the transformation vision■ Hiring, promoting and developing people who can implement thechange vision■ Reinvigorating the process with new projects, themes and change agents8. Anchoring new approaches in the culture■ Creating better performance through customer and productivityorientated behaviour, more and better leadership, and moreeffective management■ Articulating the connections between new behaviours andorganisational success■ Developing means to ensure leadership development and succession*Source: Reprinted by permission of Harvard Business School Press. FromLeading Change by Kotter J. Boston, 1996. Page 21. Copyright 1996 by theHarvard Business School Publishing Corporation; all rights reserved.4 British Journal of Occupational Therapy October 2006 69(10)The process has been invigorated by renewed smallerprojects. The team contributed to the COT guidelines onthe use of the ICF in clinical practice and was publiclyacknowledged for its work (COT 2004). This proved asignificant motivating factor for all staff, who have takenpride in the achievements of the service.Anchoring new approaches in the cultureNo discipline works in isolation. As the occupationaltherapists began to use the ICF framework, interest spreadthrough the multidisciplinary team. Presentations havebeen given to physiotherapy colleagues and the strokemultidisciplinary team. Learning about the ICF is nowpart of the induction process and was identified within the service marketing strategy for recruitment.The futureThe occupational therapy service focused on the ICFframework and further developments in the use of theclassification system are being considered. The team alsoawaits the findings of the field-testing for the ICF core setsfor the acute hospital and early post-acute rehabilitationfacilities (Grill et al 2005). ConclusionThe International Classification of Functioning, Disabilityand Health framework was implemented successfully intoclinical practice, but not without challenges during theprocess. Explicit use of change management theory, suchas the eight-stage process for implementing major change,could enable a smoother journey and enhance the uptakeof the ICF in clinical practice. Further exploratoryresearch is required to support these reflections.AcknowledgementsThe authors would like to thank Catherine Williams, Supriya Nerlekar, allmembers of the occupational therapy team, Royal Free Hampstead NHSTrust, both past and present, and Christine Craik, Director of OccupationalTherapy, Brunel University, for their contributions to the content andformat of this article.ReferencesBedeian A (2004) In: D Buchanan, A Huczynski, eds. Organizationalbehaviour. 5th ed. Upper Saddle River, NJ: Prentice Hall, 617.Buchanan D, Huczynski A, eds (2004) Organizational behaviour. 5th ed.Upper Saddle River, NJ: Prentice Hall, 614.College of Occupational Therapists (2004) Guidance for the use of theInternational Classification of Functioning, Disability and Health andthe Ottawa Charter for Health Promotion in occupational therapyservices. London: COT, 3.Geyh S, Cieza A, Schouten J, Dickson H, Frommelt P, Omar Z, Kostanjsek N,Ring H, Stucki G (2004) ICF core sets for stroke. Journal of RehabilitationMedicine, 44(Suppl), 135-41.Goodwyn L (1996) The nurse’s role as change agent in the audit cycle.Nursing Standard, 10(22), 43-46.Grill E, Erert T, Chatterji S, Kostanjsek N, Stucki G (2005) ICF core setsdevelopment for the acute hospital and early post-acute rehabilitationfacilities. Disability and Rehabilitation, 27(7/8), 361-66.Kotter J (1996) Leading change. Boston, MA: Harvard Business School Press, 21.Kubler-Ross E (1969) On death and dying. New York: Collier Books, 234-35.Managan P (1996) Why we hate change. Nursing Times, 9(92), 60.Parsley K, Corrigan P (1994) Quality improvement in nursing and healthcare.London: Chapman and Hall.Rentsch HP, Bucher P, Domment Nyffeler I, Wolf C, Hefti H, Fluri E, Wenger U,Walti C, Boyer I (2003) The implementation of the InternationalClassification of Functioning, Disability and Health (ICF) in daily practice ofneurorehabilitation: an interdisciplinary project at the Kantonsspital ofLucerne, Switzerland. Disability and Rehabilitation, 25(8), 411-21.Rycroft-Malone J, Harvey G, Kitson A, Mccormack BB, Seers K, Titchen A(2002) Getting evidence into practice: ingredients for change.Nursing Standard, 16(37), 38-43.Sauser WI, Sauser LD (2002) Changing the way we manage change.SAM Advanced Management Journal, Autumn, 34-39.Steiner W, Ryser L, Huber E, Uebelhart D, Aeschlimann A, Stucki G (2002)Use of the ICF model as a clinical problem-solving tool in physicaltherapy and rehabilitation medicine. Physical Therapy, 82(11), 1098-107.Stucki G, Cieza A, Erert T, Kostanjsek N, Chatterji S, Bedirhan Ustun T,(2002) Application of the International Classification of Functioning,Disability and Health (ICF) in clinical practice. Disability and Rehabilitation,24(5), 281-82.Tempest S, McIntyre A (2006) Using the ICF to clarify team roles anddemonstrate clinical reasoning in stroke rehabilitation. Disability andRehabilitation, 28(10), 663-67.World Health Organisation (1980) International classification ofimpairments, disabilities and handicaps: a manual of classificationrelating to the consequences of disease. Geneva: WHO.World Health Organisation (2001) International Classification ofFunctioning, Disability and Health. Geneva. WHO.AuthorsHeather Appleby, BSc(Hons), DipManagement, Head OccupationalTherapist, Royal Free Hampstead NHS Trust, London.Stephanie Tempest, MSc, BSc(Hons), PGCert, LTHE, Lecturer inOccupational Therapy, School of Health Sciences and Social Care,Mary Seacole Building, Brunel University, Uxbridge, Middlesex UB8 3PH. Email: stephanie.tempest@brunel.ac.uk

British Journal of Occupational Therapy

Bedeian A (2004) In:

Changing the way we manage change.

Guidance for the use of the International Classification of Functioning, Disability and Health and the Ottawa Charter for Health Promotion in occupational therapy services.

Huczynski A, eds (2004) Organizational behaviour. 5th ed. Upper Saddle River,

ICF core sets development for the acute hospital and early post-acute rehabilitation facilities. Disability and Rehabilitation,

Leading change.

McIntyre A

On death and dying.

Quality improvement in nursing and healthcare.

Rentsch HP,Bucher P,Domment Nyffeler I,Wolf C,Hefti H,Fluri E,Wenger

Ring H,Stucki G

Seers K,Titchen A

The nurse’s role as change agent in the audit cycle.

Use of the ICF model as a clinical problem-solving tool in physical therapy and rehabilitation medicine.

Why we hate change.

World Health Organisation

Using change management theory to implement the international classification of functioning, disability and health (ICF) in clinical practice

Using change management theory to implement the international classification of functioning, disability and health (ICF) in clinical practice

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