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Most continuous improvement programs treat change as something you implement. The team designs a future state, builds an action plan, communicates the change, and rolls it out. If people don't adopt the change, the diagnosis is usually framed as resistance -- people are stuck in their old ways, attached to the status quo, unwilling to do what's been asked of them.
This framing misses something important. People aren't usually resisting change. They're at a different point in their own change process than the team rolling out the initiative assumed. The initiative is at the action stage. The people the initiative needs are at the pre-contemplation stage, not yet aware that anything needs to change. Or they're at the contemplation stage, aware but ambivalent. Or they're in preparation but haven't yet committed. Telling people at any of these earlier stages to take action doesn't accelerate them through the change process. It usually pushes them backward.
Motivational interviewing is the methodology behavioral psychologists developed for exactly this problem. It started in therapy -- specifically, in work with patients who were ambivalent about changing health behaviors like drinking, smoking, or medication adherence. It's now used widely in healthcare for vaccination conversations, chronic disease management, and lifestyle change. And it's increasingly being applied to continuous improvement work, where the same dynamics show up whenever an improvement team needs people to adopt a new way of working.
Paola Torres has been practicing motivational interviewing in continuous improvement work for over two years at the time of this recording. She came to it the hard way -- initially dismissive when Mark Graban first introduced her to the methodology at NYU Langone, then forced to reconsider when she found herself assigned to work with a department that hadn't asked for her support and didn't want it. The methodology she dismissed turned out to be the methodology she needed.
This session walks through the theory of behavioral change, the four-stage motivational interviewing process, the specific interviewing skills the methodology uses, and three case studies from Paola's own continuous improvement practice that illustrate what the methodology looks like in real change initiatives.
Paola Torres is a Lean Six Sigma Master Black Belt and continuous improvement professional with 17 years of experience in healthcare. She currently serves as Senior Performance Improvement Manager at Healthfirst in New York City. Prior to joining Healthfirst, she was Director of Supply Chain Transformation and Integration at NYU Langone Health, where she and Mark first crossed paths. As a Lean Six Sigma practitioner and coach, she has led over 40 cross-functional kaizen and rapid improvement events. A native of Colombia, she received her BS in Microbiology from Javeriana University in Bogotá and her MPA in Health Care Management from New York University.
The session is hosted by Mark Graban, Senior Advisor at KaiNexus and the author of Lean Hospitals, Healthcare Kaizen, Measures of Success, and The Mistakes That Make Us.
The foundation Paola starts with is the stages of change model developed by James Prochaska and Carlo DiClemente in the late 1970s. Their core insight: change isn't a switch you flip. It's a process people move through in stages, and the stages don't compress to fit anyone else's timeline.
The five stages:
Pre-contemplation. The person isn't yet aware that any change is needed. They're not resisting the change because they don't see the change as relevant to them at all.
Contemplation. The person is aware of the issue but hasn't committed to doing anything about it. This is where ambivalence lives -- the simultaneous awareness that change might be good and the equally real reluctance to actually pursue it.
Preparation. The person has decided to act and is gathering what they need to do so.
Action. The person is implementing the change.
Maintenance. The change has been adopted and the person is sustaining it over time.
The error most improvement initiatives make is expecting action from people who are still in pre-contemplation or contemplation. A primary care provider prescribes a healthier diet, and the patient says they come from a family of red-meat eaters who all lived to 90 -- the provider is treating the patient as if they're in the action stage, but the patient is in pre-contemplation, not yet convinced that diet matters. A manager creates a new standard operating procedure and complains that staff aren't following it -- the manager is in the action stage (they went through their own change process to identify the need for the standard), but the staff hasn't gone through that process yet. Some are in pre-contemplation. Some are in contemplation. Expecting them to skip stages and join the manager in action is unrealistic.
The implication for change management work: motivational interviewing is the methodology for the early stages. You use it to help people move from pre-contemplation to contemplation, from contemplation to preparation. By the time people are in preparation or action, the work shifts to planning and implementation. The conversations look different at different stages because the people are different stages.
Two concepts from motivational interviewing matter enough to name explicitly.
The righting reflex. When someone tells us about a problem they're facing, the natural human response is to want to fix it. We see what they should do. We offer advice. We tell them how to solve the problem. This impulse -- the righting reflex -- comes from a place of genuine care, especially when you're a consultant or a counselor or a clinical practitioner. The impulse itself isn't bad. The problem is that it almost always backfires.
Paola illustrates with a small personal story. During the pandemic, she'd been wanting to wake up at 7 AM and go for a run, having read that morning exercise is good for sleep quality. She mentioned this to a friend. The friend offered immediate, sensible advice: set an alarm for 7:30 that just says "run." As her friend explained the obvious solution, Paola found herself feeling uncomfortable. Then she found herself questioning whether she even needed to exercise in the morning. The friend's good-faith advice had activated the other voice in her head -- the voice that said this whole project wasn't necessary.
This is the righting reflex in action. The person trying to help articulates the case for change, which leaves the person they're helping free to articulate the case against. People tend to implement what they hear themselves say. If the helper takes the change side of the argument, the person needing to change takes the no-change side, and the conversation actively moves them away from action.
Ambivalence. People considering change carry both voices simultaneously. The yes voice -- the reasons for change, what MI calls "change talk." And the no voice -- the reasons against, what MI calls "sustain talk." Ambivalence isn't a sign of weakness or confusion. It's the normal state of someone considering a meaningful change. The work of motivational interviewing is to help people resolve their ambivalence in the direction of change -- not by arguing them into it, but by helping them hear themselves articulate the reasons that matter to them.
The shift in mindset is significant. Most improvement work is structured around the change agent articulating why the change matters. Motivational interviewing inverts this. The change agent's job is to create the conditions where the person can articulate, in their own words, why the change matters to them. The person doing the talking is the person doing the persuading.
Motivational interviewing organizes the change conversation into four processes that the change agent and the person move through in sequence. Each process has its own purpose and its own characteristic interviewing techniques.
Engaging. Building the relationship. Establishing trust. This is the foundation. Paola's diagnostic question: think about the last time you met your in-laws. Did you ask every question you wanted to ask? Almost no one does. The engaging phase is the same kind of work -- learning enough to build the relationship without asking so much that you damage the relationship before it exists. With customers who reached out to you, this phase can be relatively short. With customers who were told to work with you, it can take significant time.
Focusing. Narrowing the scope. Identifying what the conversation is actually about. This is where the change agent and the person agree on the specific issue or goal. Skipping this step produces conversations where everyone is technically talking but nobody is talking about the same thing.
Evoking. Drawing out the person's own reasons for change. This is the heart of the methodology. The change agent's job is to ask questions and use interviewing skills that help the person articulate change talk -- desire, ability, reasons, and need. The change agent is not arguing for the change. The change agent is helping the person hear themselves arguing for the change.
Planning. Translating the resolved ambivalence into concrete action. Once a person has worked through their ambivalence and is genuinely committed, the planning phase is relatively straightforward -- it's the action plan work that's familiar from any improvement methodology.
Movement through the four processes isn't strictly linear. A conversation can move from engaging to focusing and then back to engaging when something breaks the relationship. The processes serve as anchors that let the change agent diagnose where the conversation is and what kind of work the moment calls for.
Motivational interviewing uses four interviewing skills, often summarized as OARS:
Open-ended questions. Questions that invite exploration rather than yes-or-no answers. "What concerns do you have about this change?" rather than "Are you concerned about this change?"
Affirmations. Specific recognition of the person's strengths, efforts, or values. "You manage a really complex operation. We can't run a hospital without you." Affirmations restore autonomy and rebuild self-efficacy, particularly important when the person feels overwhelmed or controlled.
Reflections. Active listening responses that mirror back what the person has said, often emphasizing the positive or the underlying value. Reflections are not paraphrasing. They're choices about which part of what was said to amplify.
Summaries. Periodic reviews of the conversation that highlight the change talk the person has expressed and consolidate the direction the conversation is moving.
None of these skills is unique to MI. What makes them MI-specific is how they're framed and what purpose they serve. A reflection in general coaching might highlight whatever the coach finds interesting. A reflection in MI deliberately highlights the change talk the person has expressed -- it amplifies the parts of the conversation that move toward action. An affirmation in general coaching might just be encouragement. An affirmation in MI is targeted to restore the person's sense that they can do what's being considered.
The interviewing skills also can't be separated from the underlying spirit of MI -- collaboration, acceptance, empathy, and partnership. An open-ended question delivered without genuine curiosity is just an interrogation. An affirmation delivered without sincerity is flattery. The skills work because the underlying stance is one of respect for the person's autonomy. Strip the stance away and the techniques don't produce the same results.
Paola's first case study illustrates the engaging phase and the consequences of being pushed into a department that didn't request your support.
The setting: NYU Langone's supply chain department. Paola and other process improvement practitioners were told to find defects and identify reasons why nurses weren't getting what they needed to do their jobs. The push came from above. The supply chain leaders hadn't requested the work and didn't see themselves as having the problem the improvement team was being sent to investigate.
The leaders were in pre-contemplation. There was no awareness of the issues the improvement team was being asked to address. The improvement team did some good relationship-building and trust-building work, but they also made several mistakes that hindered progress to the focusing phase.
The common statements the team heard during meetings: "We already worked with a consultant last year and nothing changed." "Kaizen events take four days and at the end there are no results."
The wrong responses, both of which the team was tempted toward: arguing the point ("yes, but we've had good results in the clinical departments") or selling past outcomes. Both responses break the engaging work. They put the change agent in the position of defending against the person's concerns rather than understanding them.
The MI-aligned response Paola identifies in retrospect: reflection plus affirmation. "I understand that it must be tremendously difficult to work with another department or with a consultant and not get the results that you want. But I know that what you really care about at the end of the day is that the clinical care team gets what they need."
This response does several things at once. It acknowledges the person's experience without arguing. It identifies the positive underlying value (caring about the clinical care team) that the person and the improvement team both share. It establishes the relationship on the ground of shared values rather than on the ground of contested past performance.
The affirmation tools matter especially here. People who aren't engaged often aren't engaged because they've lost their sense of efficacy -- they've tried multiple things, none of them have worked, and they're now defending the small amount of autonomy they have left. Affirmations restore that autonomy. "You manage a really complex operation. We can't run a hospital without you." These statements are easy to deliver and have outsized positive effects on relationships when delivered sincerely.
The traps Paola names for the engaging phase:
The premature focus trap. Trying to focus the conversation before the relationship exists to support focusing. "Let's talk about your scheduling problem" when the person hasn't yet agreed there's a scheduling problem.
The labeling trap. Diagnosing the issue too quickly. "This is really about alcoholism" or "This is really about your reluctance to delegate" -- premature labels close down the exploration the engaging phase requires.
The expert trap. Behaving like a consultant on a checklist. "Do you have your scorecard? Do you have the data? How do you quantify this?" Asking these questions in the engaging phase signals to the person that they're a task to be completed rather than someone the change agent actually wants to understand.
The second case study illustrates a different starting condition -- a customer that was actually ready to engage from the beginning.
The setting: an accounts payable department at the same organization. The director had reached out to the Lean team directly. Many of the department's processes were manual, automation was a priority, and the director wanted help structuring the work. The engaging phase was relatively short because the request itself established the relationship.
The team could move into focusing relatively quickly. The MI work shifts to a different set of techniques and a different set of risks.
The risk in the focusing phase: pushing too hard on what the focus should be. The change agent often has a clearer picture of where the work needs to go than the customer does. The temptation is to drive the focus. This usually fails. The customer needs to identify and commit to the focus, not have it imposed.
What Paola heard the accounts payable team say: "We want to ensure our members' account balances are accurate. We want to decrease the time it takes. But I don't know where to start." Statements like the last one are signals that the customer is ready for the change agent to offer expertise, but the offer needs to be made in a way that preserves the customer's autonomy.
The technique Paola highlights here is called "elicit-provide-elicit." It's a structured way to share expertise while keeping the customer in control of the direction.
The pattern:
Elicit the customer's permission. "Would it be okay if I shared with you how I've approached this before?"
Provide the perspective or advice. "Your processes are all connected, so it can help to identify the triggers at the beginning and end points first. Then prioritize them and decide where to start."
Elicit the customer's response. "What are your thoughts about that approach?"
The structure is significant. The change agent is offering expertise, but only after explicit permission, and the offer is followed immediately by an invitation for the customer to weigh in. The customer remains in control. The expertise is available without being imposed.
The traps in the focusing phase that Paola names:
Telling people what to do. Every time she's done it in the focusing phase, it backfires. The customer responds with disagreement or disengagement.
Treating the customer like a task on a checklist. Moving through the phases of the methodology without genuinely caring whether the customer is getting what they need. The customer can feel the difference.
Taking control of brainstorming. When the team is generating possibilities, let them generate. Don't move them along faster than their own thinking is ready to move. The brainstorming itself is part of the change process.
The third case study illustrates the evoking phase, which Paola describes as the heart of MI work.
The setting: a kaizen event at an emergency department. By the third day, the team had completed the engaging and focusing work and was ready to design the future state and develop interventions. The statements the team was making had a characteristic shape: "We would like to do this, but..." This "but" pattern is typical of the evoking phase -- the team is on the verge of articulating commitment but hasn't yet resolved their ambivalence.
The work in the evoking phase is to amplify change talk. This means asking questions and using interviewing skills that draw out the four elements of change talk, summarized in MI as DARN-CATs.
The DARN portion focuses on building the case for change:
Desire. What does the person want? "What services do you envision providing five years from now?" Questions like this surface the desired future state. The kaizen team developed a vision statement that helped each member articulate what they wanted, in their own words.
Ability. Can the person actually do this? "If you wanted to call a patient specialist, how much time would that take? Could you actually do it?" Questions like this help the person envision themselves taking the action successfully. Self-efficacy beliefs are often the silent constraint on whether people commit to change.
Reasons. What are the advantages? "What are some of the reasons to call the providers? What can the clinical care team do better if you do this?" Questions like this surface the specific benefits the person can articulate.
Need. How important is this? "How important is it for you as a nurse to talk with the patient specialist?" Questions like this help the person identify the urgency they feel.
The CATs portion (commitment, activation, taking steps) belongs to the planning phase. Evoking is about DARN -- desire, ability, reasons, need. The change agent's job is to ask the questions that help the person articulate these elements in their own words.
The traps in the evoking phase that Paola names:
Taking sides. Arguing for the change. "If we do this, we'll bring in more revenue." Statements like this position the change agent as the advocate for the change, which leaves the person free to be the advocate against it.
Asking judgmental questions. Paola tells a story from the ER kaizen where she shared a personal experience of difficulty getting medical records during her son's delivery. The story was meant to illustrate why coordination of care matters. It landed as judgment -- as if she were saying the ER team should have done better. Even when the intent isn't judgmental, language that sounds judgmental hinders progress.
The planning phase is the shortest section of Paola's session, and that's appropriate. When the earlier work has been done well -- when the person has moved through engaging, focusing, and evoking and has resolved their ambivalence in the direction of change -- the planning phase is relatively straightforward. It's the familiar work of building an action plan, identifying who does what by when, designing the pilot, and structuring the implementation.
The implicit point is that most of the difficulty in change management lives before planning, not in planning. Most improvement teams have plenty of skill in planning. What's often missing is the work that should have come before -- the engaging, focusing, and evoking that produces the genuine commitment planning depends on.
The connection between motivational interviewing and a continuous improvement platform is real but worth being honest about. The platform doesn't deliver MI conversations. People do. The methodology is in the relationship, not in the software.
That said, several aspects of how a CI platform supports improvement work intersect with the MI framework in useful ways.
The platform makes the gap visible between what's been planned and what's been adopted. Improvement initiatives documented in KaiNexus -- with their countermeasures, owners, and validation tasks -- create a record that's easy to inspect against actual adoption. When a planned change isn't being adopted, the platform surfaces the gap quickly enough that the conversation about why can happen while the initiative is still recoverable. Without that visibility, the gap often becomes apparent only after the initiative has quietly died.
The platform supports the planning phase well, which means the change agent's attention can be freed for the earlier phases. If the action plan, the task assignments, the timelines, and the validation are all handled by the platform, the change agent doesn't need to spend their conversational time managing project mechanics. They can spend it on the engaging, focusing, and evoking work that determines whether the action plan actually happens.
The platform's records of past improvement work provide the raw material for affirmations. "Your team improved patient throughput by 18% on the orthopedic unit last year" is a much more concrete affirmation than "you all do great work." The platform makes the specific affirmations possible because the specific record exists.
The platform's ability to make improvements visible across the organization supports the change talk work. When a person says "this kind of change won't work here," being able to surface examples of similar changes that have worked in similar departments creates a real anchor for the conversation. The change agent isn't arguing. They're pointing to evidence that the person can examine and respond to.
None of this substitutes for the human work Paola describes. Motivational interviewing is a relational discipline. The platform supports the work; it doesn't replace it. The improvement programs that sustain are the ones where the platform handles the project mechanics well enough that the people running the program can spend their attention on the conversations that determine whether change actually happens.
Paola Torres is a Lean Six Sigma Master Black Belt and continuous improvement professional with 17 years of experience in healthcare. She serves as Senior Performance Improvement Manager at Healthfirst in New York City. Prior to joining Healthfirst, she was Director of Supply Chain Transformation and Integration at NYU Langone Health. As a Lean Six Sigma practitioner and coach, she has led over 40 cross-functional kaizen and rapid improvement events, integrating change management concepts and adult learning theory into applied process improvement science. A native of Colombia, she received her BS in Microbiology from Javeriana University in Bogotá and her MPA in Health Care Management from New York University.
What is motivational interviewing?
A communication style developed in behavioral therapy that helps people resolve their ambivalence about change. The core principle is that people are more likely to act on reasons they identify themselves than on reasons supplied by someone else. The change agent's job is to ask questions and listen in ways that help the person articulate their own reasons for change, rather than telling them why they should change. The methodology was originally developed for clinical settings (smoking cessation, alcohol use, medication adherence) and has been applied widely to other domains where behavior change is the goal -- including continuous improvement work.
Why doesn't telling people what to do work?
Because of what motivational interviewing calls the righting reflex. When someone with authority or expertise tells a person what to do, the person often finds themselves articulating the reasons they shouldn't or can't. The act of being told activates the resistance. People are more likely to act on reasons they hear themselves say than on reasons supplied by others. Telling positions the change agent as the advocate for the change, which leaves the person free to be the advocate against it. The dynamic is psychological, not rational -- it happens even when the person agrees with the substance of what they're being told.
What are the stages of change?
The model developed by Prochaska and DiClemente identifies five stages: pre-contemplation (not yet aware change is needed), contemplation (aware but ambivalent), preparation (committed to act and gathering resources), action (implementing the change), and maintenance (sustaining the change over time). The error most change initiatives make is expecting action from people who are still in pre-contemplation or contemplation. Motivational interviewing is specifically the methodology for moving people through the earlier stages so that by the time the initiative reaches action, the people involved are actually ready.
What is change talk and why does it matter?
Change talk is what the person says that supports change -- statements about desire, ability, reasons, and need. Sustain talk is what the person says that supports staying the same. Most people considering change carry both voices simultaneously. The work of motivational interviewing is to amplify change talk and reduce the prominence of sustain talk, on the principle that people tend to implement what they hear themselves say. When the person articulates the reasons for change in their own words, the commitment that follows is durable. When someone else articulates the reasons, the commitment depends on continued external pressure.
How does motivational interviewing differ from regular coaching or facilitation?
The interviewing skills are similar -- open-ended questions, reflections, affirmations, summaries. What's distinctive is how the skills are framed and what purpose they serve. A reflection in general coaching might highlight whatever the coach finds interesting. A reflection in MI specifically amplifies change talk -- it draws out and reinforces the parts of what the person said that move toward action. An affirmation in general coaching is general encouragement. An affirmation in MI is targeted to restore the person's sense of autonomy or efficacy. The techniques are the same. The deliberate use of them in service of resolving ambivalence is what makes them MI.
What is the "elicit-provide-elicit" technique?
A structured way for a change agent to share expertise while preserving the customer's autonomy. Elicit permission first ("Would it be okay if I shared what I've seen work?"). Provide the perspective. Then elicit the customer's response ("What do you think about that approach?"). The structure prevents the common failure mode of consultants offering unsolicited advice, which usually triggers resistance. The customer remains in control of whether the advice gets used, even when they specifically asked for help.
Can motivational interviewing be used with someone who's hostile or actively opposed?
The first move is to understand why, not to argue with the position. If someone refuses to wear a mask or refuses to be vaccinated, the MI-aligned approach is to ask questions about their concerns and listen genuinely, rather than presenting them with the arguments for the behavior they're refusing. This isn't agreement. It's the recognition that people who feel pushed will push back harder. People who feel heard sometimes find their own way to a different position. The methodology isn't a guarantee -- there are people whose minds won't change. But arguing rarely changes anyone's mind, and listening sometimes does.
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