Table 1. Associations between Kotter’s change model and the process of age-friendly hospital certification.

Kotter’s 8-step change model		Process and associated standards of age-friendly hospital certification (AFH certification)
Steps	Suggested strategies/actions	Strategy applied to achieve AFH certification standards	AFH certification standards
Step 1. Create a sense of urgency	• Examine market and competitive realities. • Provide evidence from outside the organization that change is necessary. • Identify and discuss crisis, potential crisis, or major opportunities.	• Conduct SWOT analysis - The case study hospital (Health Promotion Committee) collected information on SWOT and analyzed it prior to making the decision to apply for AFH certification.	Standard 1. Management policy • developing an age-friendly policy
		• The Health Promotion Committee confirms, declares, and formulates policies through internal or supervisory communication.	Standard 1. Management policy • organizational support
Step 2. Build the guiding team	• Assemble a group with enough power to lead the change effort. • Attract key leaders of change by showing enthusiasm and commitment. • Encourage the group to work together as a team.	• The steer committee was constituted. The 20 members invited to join were superintendents, directors of medical and administrative departments, nursing supervisors, medical professional representatives, clerks, aged patients, family caregivers, and volunteers.	Standard 1. Management policy • organizational support
		• A nursing supervisor was appointed to be the CEO. • The PDCA method was employed to develop, implement, and evaluate the process of AFH certification.	Standard 2. Communication and services • communication Standard 1. Management policy • continuous monitoring and improvement
Step 3. Create a vision	• Create a vision to help direct the change effort. • Develop strategies for achieving that vision.	• Collective decision making • Build consensus - All employees were broadly engaged in the entire conversation, which consisted of “collective decision making (across the hospital), consensus building, and strategy formulation for the vision.”	Standard 2. Communication and services • communication • services (internal customers: employees; external customers: patients, family, and community)
		• Formulate a strategy for the vision The teams were encouraged to develop a variety of communication channels to convey the authentication steps and strategies. • Pretest questionnaire Pretest questionnaires were administered at this stage.	Standard 1. Management policy • continuous monitoring and improvement
Step 4. Communicate the vision	• Build alignment and engagement through stories. • Use every vehicle possible to communicate the new vision and strategies. • Keep communication simple and heartfelt. • Teach new behaviors by the example of the guiding coalition.	• The common vision—“love God, love people, and respect life—age-friendly”—was shared with staff. • The CEO led internal marketing efforts. • Internal marketing communication - The internal marketing communication approach focused on short- to medium-range targets, including possible communication channels, large and small conferences in hospitals, websites, publications within the hospital, regular e-mail bulletins, etc. - Multiple communication channels ensured a common vision for the hospital staff. - Authorized employee participation and a distress strategy indicated positive attitudes toward employees.	Standard 2. Communication and services • communication services (internal customers: employees; external customers: patients, family, and community)
		• Education (workshop, continued education, experiential ageing-simulation learning, etc.) - To meet the healthcare needs of elderly, workshops, continued education, and ageing-experience activities were conducted to ensure hospital-wide participation in the comprehensive review of operational procedures, the overall environment, and equipment.	Standard 2. Communication and services • communication • services
		- The training includes 2 hours of age-friendly education (continuing education) and 3 hours of experiential ageing-simulation activity (Including the necessary courses for on-the-job and new employee training).	Standard 4. Physical environment • hardware environment: “universal design” • traffic and action • signs and identification
		- The method and content of communications between hospital workers, elderly, and the service processes needed to be improved to establish friendly, respectful, and accessible services for elderly in accordance with communication and service standards.	Standard 2. Communication and services • communication • services
Step 5. Empower action	• Remove obstacles to change. • Change systems or structures that work against the vision.	• Multidisciplinary team - This step required the cooperation of the professional teams; therefore, interdisciplinary cooperative strategies were implemented. • The CEO convened a meeting every 2 weeks to discuss policies and measures in such areas as general affairs, medical affairs, and health communications to unite outpatient nursing staff and administrative personnel. - The CEO convened a meeting with nursing supervisors, nutritionists, physical therapists, and mental health physicians, who jointly formulated the following measure: the reevaluation of older inpatient assessment forms in areas including physical function, mental status, nutritional screening, and fall risks, and the integration of all forms into one high-risk screening form. • Patient support groups - Service desks and service windows were established for elderly so they could receive priority appointment services. - Service processes were emphasized, such as reducing wait times and keeping the sixth appointment number for an elderly patient. - Elderly were provided with information regarding convenient transportation, reserved seating, extra space for entering and exiting vehicles, calling cabs for patients, and shuttle buses. - A website was created, giving patients (family caregivers) and staff access to “health information on health ageing, risk factors, and diseases.” - Improvements in older adult communication were achieved through the use of larger fonts and clearer diagrams in health education tools and pamphlets and the use of other age-appropriate methods, such as styluses and electronic communicators. - Emphasis was placed on respect for elderly in all care processes by proactively informing them of their diagnoses, examination results, treatments, and conditions. They were physically able to, as well as obtaining informed consent from self-aware elderly. - Community resources and patient support groups were united to meet the continual care standard.	Standard 3. Care processes • patient assessment • intervention and management (guidelines on multidisciplinary geriatric assessment and interventions on high-risk seniors are available) Standard 4. Physical environment • hardware environment: “universal design” • traffic and action • signs and identification Standard 2. Communication and services • communication • services Standard 3. Care processes • community partnership and continuity of care (a list of health and social care providers working in partnership with the hospital is available)
Step 6. Create short-term wins	• Plan for and achieve visible performance improvements. • Recognize and reward those involved in bringing the improvements to life.	• Mobilization - A comprehensive review and authorized employee participation (mobilization) of the hospital environment was conducted. - When the goals have been met, the employees will be motivated to fine tune and expand the change. •Strategies are developed for short-term wins. - By acknowledging and rewarding employees who are closely involved in the change process, it will be clear across the board that the company is changing course.	Standard 4. Physical environment • hardware environment: “universal design” • traffic and action • signs and identification
Step 7. Build on the changes	• Plan for and create visible performance improvements. • Recognize and reward personnel involved in the improvements. • Reinforce the behaviors shown that led to the improvements.	• Repair decoration The hospital environment was improved based on two general principles: universal design and barrier-free issues related to ageing. - For example, considering the safety of elderly entering and exiting hospital rooms, the colors brown and yellow, which are not easily distinguishable, were eliminated from all hospital rooms and facilities. - Larger fonts and contrasting colors were used on all signage within the hospital; reception chairs were replaced with those with armrests; the slope was adjusted on all ramps, on which nonslip strips were also installed; and warning signs were posted.	Standard 4. Physical environment • hardware environment: “universal design” • -traffic and action • -signs and identification
		• Posttest questionnaire - The posttest questionnaire was administered at this stage.	Standard 1. Management policy • continuous monitoring and improvement
Step 8. Institute the change	• Articulate the connections between the new behaviors and corporate success.	• Certification success - The hospital received AFH certification for the first time on September 3, 2012, and was recertified to 2021 in 2015. • Intercollegiate exchange visit - Intercollegiate exchange visit took place on March 29, 2016.	Standard 1. Management policy • continuous monitoring and improvement

Note: AFH = age-friendly hospital; SWOT = strength, weakness, opportunity, threat; PDCA = plan-do-check-act.