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In order to implement business process reengineering successfully, organizations find that they need to combine a variety of change initiatives. Yet, most of the empirical literature dwells on a single change initiative. Integrating multiple change initiatives requires a structural learning mechanism. The learning mechanism is created to lead, design, and implement the overall change effort. This paper reports on BPR at Blue Shield of California. The theoretical implications of system-wide transformation and learning mechanisms - based on the integration of BPR with other change initiatives - within the rapidly changing health care competitive context are discussed.