Journal of Womens Health, Issues and Care ISSN: 2325-9795

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Research Article, J Womens Health Issues Care Vol: 5 Issue: 5

Kotter's Eight-Step Change Model: One Centre's Experience for Transition to the GnRH Antagonist Protocol

Tan SQ1, Lim WW1, Liu SL2, Phoon WLJ2, Tan TY2, Viardot V2, Chan J2, Nadarajah S2 and Tan HH2
1Department of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore
2Department of Reproductive Medicine, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore
Corresponding author : Shu Qi Tan
Senior Resident, Department of Obstetrics and Gynaecology, KK Women’s and Children’s Hospital, 100 Bukit Timah Road-229899, Singapore
E-mail: [email protected]
Received: April 19, 2016 Accepted: June 22, 2016 Published: June 27, 2016
Citation: Tan SQ, Lim WW, Liu SL, Phoon WLJ, Tan TY, et al. (2016) Kotter’s Eight-Step Change Model: One Centre’s Experience for Transition to the GnRH Antagonist Protocol. J Womens Health, Issues Care 5:5. doi:10.4172/2325-9795.1000246


Background: Gonadotropin releasing hormone (GnRH) agonist cycle was the traditional method of ovarian stimulation at KK Women’s and Children’s Hospital IVF Centre. This long cycle involved many injections, with a poor side effect profile. The GnRH antagonist cycle was introduced in year 2000, with fewer injections per cycle and better side effect profile.
Aim: Our department aims to encourage transition from the GnRH agonist cycle to GnRH antagonist cycle, with complete changeover by 2013. Methods: The transformation process was organized according to Kotter’s Eight-Step Change Model from the first half of 2012.
Results: This transition led to a five times reduction in the number of oocyte pick-ups on a non-working day. This reduced out-of-hours demands, while maintaining the pregnancy and live birth rates. Incidence of ovarian hyper stimulation syndrome was reduced from 4.0% to 2.2%. By early 2013, 77.2% of ovarian stimulation was done with GnRH antagonist cycles.
Conclusion: Kotter’s Eight-Step Change Model was useful to encourage positive transformation. Garnering support from the various users was essential for the transition to GnRH antagonist cycles, which led to enhancement in different dimensions of clinical quality including patient centered processes, effectiveness of treatment and efficiency of service, while maintaining patient’s safety.

Keywords: IVF protocol; Transition; Kotter’s transformation


IVF protocol; Transition; Kotter’s transformation


Scheduling of in-vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI) cycles has been a concern for fertility units due to the difficulty faced with balancing even workload distribution during the week, as well as avoiding unplanned procedures during the weekends. Cycle scheduling aims to improve manpower organization within the department. In addition, it serves to reduce out-of-hours demand in view of limited manpower over the weekend.
Traditionally, gonadotrophin releasing hormone (GnRH) agonists were the default option for ovarian stimulation at KK IVF Centre in KK Women’s and Children’s Hospital. In the past decade, GnRH antagonists surfaced. They work via expeditious and immediate gonadotrophin suppression, giving the advantage of a shorter treatment cycle. Studies have also shown comparable live birth rates and ongoing pregnancy rates for both protocols [1]. GnRH antagonist cycles, additionally, have the advantages of a significant reduction in incidence of severe ovarian hyperstimulation syndrome (up to 60%) and a shorter duration of stimulation [2], with resultant minimized patient discomfort and side effects e.g. symptoms of hypo-oestrogenaemia like hot flushes, headaches, sleep disturbances, which are commonly observed in the GnRH agonist protocols during the desensitization period [3,4].
Despite the clear advantages of GnRH antagonist protocols, our department, like many centres, was resistant to change in view of fixed mind-sets, fear of disturbances in logistics and a concern of worsening outcomes. Kotter’s Eight-step Change Model was selected to develop and organize the transition from agonist to antagonist cycles at our centre.

Materials and Methods

Kotter’s Eight-Step Change Model consists of eight important steps to successfully change a process1, as seen in Figure 1. For a successful transition, it must be a change that is desired in the department. A sense of urgency for the need for change must be established to spark motivation to change things. Strong leadership and visible support is crucial within the department. A clear vision is created to help the team understand the reason for the change, and the team members must be empowered to act on the vision. Short term targets can be set to create short term wins, and the consequent improvements can be used to drive further changes. Finally, this change should be institutionalized with time.
Figure 1: 8 Steps of Kotter’s Transformation.


Step 1: Establishing sense of urgency
The first step in Kotter’s model is establishing a sense of urgency. It was crucial that the clinicians in the department understood the advantages of GnRH antagonist protocols over our current default protocol, and were willing to “buy-in” the process of transition. For this first step, a review of 2011 practice noted that 27.2% of stimulation cycles were via GnRH antagonist cycle, while majority of cycles were still via GnRH agonist cycle. Department meetings highlighted the intention for transition to the team.
Step 2: Forming a powerful coalition
Kotter’s second step calls for a strong leader with sufficient power to lead the change effort within the team. This move was led by the head of department of the IVF centre, starting January 2012. However, the support of the clinicians in the department was fundamental to successful transition to predominant GnRH antagonist cycles. Protected department meeting times were organized to create “buyin” from the staff through brain-storming sessions.
Step 3: Creating a vision
The third step was creating a vision. With a realistic goal in mind, it was aimed to have a successful transition to predominant antagonist cycles by 2013.
Step 4: Communicating the vision
The fourth step is communicating the vision. It was important to have the department clinicians exposed to the transformation and understand the steps taken. Communication of these steps to be implemented was important. Having a regular department meeting was the main tool for dissemination of such information. It also formed an avenue for discussion of main obstacles foreseen with the transition, as well as an opportunity for clinicians to raise their concerns. A major hurdle identified was the scheduling of cycles. Our centre operates on a basis of a 6-day working week from Monday to Saturday. It was important to avoid oocyte pickup (OPU) during weekends, distribute workload throughout the week, optimize manpower adequately, and maintain patient’s safety.
Step 5: Empowering others to act on the vision
Recognizing our clinicians’ concerns, the department decided to design and plan a pilot trial to enroll patients into the GnRH antagonist cycles. The primary aim of this pilot study was to encourage the department to ‘buy-in’ to the transition, as they experience the positive benefits of the antagonist cycles. Implementing the transition on a small scale also allows for identification of other possible obstacles to the transition. Clinicians were empowered to have a trial of this transition prior to full transition.
Step 6: Planning for and creating short term wins
The pilot study was launched in July 2012, with the primary short term win to reduce the number of oocyte pick-up procedures over the weekends, while maintaining clinical pregnancy rates and live birth rates (secondary outcomes). Innovative cycle scheduling techniques including pre-cycle treatment with oral contraceptive pills or estradiol valerate were tried. The case-control pilot study [2] prospectively recruited all women whose day 2 of menstrual cycle occurred on a Tuesday or Wednesday from July to December 2012.
Step 7: Consolidating improvements and producing more change
The results of the pilot study were reviewed [5,6]. A total of 140 patients due to start ovarian stimulation were included. The control group had 70 patients with no pre-treatment prior to stimulation with GnRH antagonists. The study group had 70 patients with 3 days of GnRH antagonist pre-treatment. GnRH antagonist injections were started on day 5 for both groups.
The patient demographics and clinical characteristics were comparable in both groups for age, body mass index, parity, race, basal early follicular phase Follicular Stimulating Hormone levels, anti-Mullerian hormone levels, and duration of infertility. The study group had a 5 times reduction in the number of OPU procedures occurring on a Saturday. This was comparing 7.1% vs. 34.3% in the control group, with an odds-ratio of 0.14 (p<0.001) after an adjustment was made for age. The embryo transfer cancellation rate was similar in both groups (5.7% vs. 8.6%) (Table 1).
Table 1: Comparison of primary outcome, oocyte pick up on Saturdays.
The clinical pregnancy rate (CPR) and live birth rate (LBR) did not differ statistically between the two groups: CPR 40.9% and 37.5%; LBR 27.3% and 31.3% for pre-treatment group and control group respectively. Both CPR and LBR were still comparable after adjustment for age, infertility diagnosis, starting and total dose of FSH, and number of oocytes retrieved in the multivariable model.
Step 8: Institutionalizing new approaches
The results from our pilot study were encouraging, highlighting clear advantages of GnRH antagonist pre-treatment followed by the GnRH antagonist regime. This served to reassure our clinicians on their doubts of the unknown regarding the antagonist cycles, and has positively influenced the transition to increase the use of antagonist cycles. By 2013, antagonist short cycles had overtaken the traditional agonist cycles to form nearly 80% of IVF cycles at KK IVF centre (Figure 2). The steps of transformation are summarized in Table 2.
Figure 2: Ratio of antagonist versus agonist cycles.
Table 2: Plan for transition from GnRH agonist cycles to antagonist cycles using the Kotter’s Eight-Step Change Model.


The use of Kotter’s Model allows us to abide by a step-wise progression towards change, while taking into account differences in individuals’ perceptions, goals and needs. This plays an essential role in assimilating an individual to the change process. The adoption of Kotter’s Eight-Step Change Model to successfully introduce change in practices has been described in various other settings.
A study [7] was conducted by the Cancer Care Ontario to launch an initiative using Kotter’s model to increase peer review of plans for patients receiving radical intent radiation treatment (RT). This study has produced rudimentary results demonstrating that the proportion of radical intent RT courses peer reviewed province wide increased from 43.5% in April 2013 to 68.0% in March 2015, suggesting a success in the use of the model for instituting change.
Kotter’s model is also widely used to bring about transformational changes in an administrative context. A study [8] conducted in 2013 demonstrated the use of Kotter’s Eight-Step Change Model to digitally transform an orthopaedic surgical practice in Toronto, Canada from paper-based records to electronic medical records (EMR). Perceived barriers to the adoption of EMR were identified and addressed, with each step of the Kotter’s model explored in detail. Results showed that prior to implementation of the model, digital rate was 54% as compared to 98% post-implementation. This once again indicates that Kotter’s model can be an effective tool in bringing about transformational change.
In our practice, the case of using GnRH-antagonists in IVF cycles to develop a more ‘patient –friendly IVF’ has been convincingly made. With its efficacy, ease of use and flexibility of treatment, GnRH antagonist protocol has proven itself to be promising alternative for ovarian stimulation. In our centre, Kotter’s Eight-Step Change Model has played a fundamental role in the transition of GnRH agonist to antagonist cycle. This has resulted in a positive impact on our practice and on patient safety profile, leading to improved patient safety and satisfaction, clinical satisfaction, as well as departmental optimization of workload distribution. In a span of a year, GnRH antagonist cycles have superceded GnRH agonist cycles to form the majority of IVF cycles.


Change is never easy. For a successful transition in culture, there has to be a change in mind-set. Kotter’s Eight-Step Change Model addresses this need and encourages the individual to be involved in the desire for change. We have shown the effectiveness of this model in our centre and hope to use it to implement other beneficial changes in the future.


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