Change at the individual level is described by several models. The ''stages of change" model was developed to describe smoking cessation (Prochaska and DiClemente, 1986). Readiness for change progresses through stages of precontemplation, contemplation, action, and maintenance. For maximum impact, health interventions are chosen with attention to the individual's stage of readiness.
The Health Belief Model views behavioral change as the result of "triggers" (Rosenstock et al., 1988). Beliefs about susceptibility, severity, benefits of treatment, and barriers to treatment contribute to individuals' willingness to change their behavior. The committee was told that this concept, along with other models of behavioral change, may also be important in studying the change process at an organizational level.
An organizational model of change described by Lewin (1976) is based on a three-stage process that includes "unfreezing" the old behavior, cognitive recognition of the need for a new behavior, and "refreezing" the new behavior. This description is accurate for many organizational change processes. In health care, however, change is currently so rapid that behavior is in a seemingly constant state of unfreezing and refreezing.
Other models also describe organizational change as a staged process (Beckhard and Harris, 1987; Bridges, 1980). Thompson and Kinne (1990) offer a community development model of change that considers change on a continuum from individual to community. The PRECEDE-PROCEED model developed by Green and Kreuter (1991) is also frequently used in health promotion. It approaches change through factors that are grouped as predisposing, enabling, or reinforcing.
Both initiating performance monitoring and responding to the problems identified by performance monitoring systems require changes in the community and on the part of various stakeholders. Alberta, Canada, provides an example of the change process in health care.
Several tensions are influencing health care: individual versus