School for Health and Care Radicals; International Forum on Quality and Safety in Healthcare 2014

@HelenBevan @BoelGare @JackieLynton #Quality 2014 #M5

The School for Health and Care Radicals

Helen Bevan, @Helen Bevan

NHS Improving Quality, EnglandBoel Andersson Gäre

@BoelGareJönköping County Council and the Jönköping Academy , Sweden;

Jackie Lynton@jackieLynton

NHS Improving Quality, England

Why the School for Health & Care Radicals?It’s tough being a change agent in health and care, particularly

when other people don’t always get it or want to change.

Yet big change happens in health and care only because of heretics and radicals: passionate people who are willing to take responsibility for change. We are people who support the goals

of our health and care systems, but also want to change existing thinking and practice and improve care for patients

and people who use services.

The School for Health and Care Radicals provides tools, ideas and connections with a community of radicals to help us thrive

and survive as agents of positive change

We are a learning community

• We encourage you to tweet during the day using the hashtags #Quality2014 and #M5

• We hope other radicals will join in virtually during the day

• We will produce a summary of the day using Storify.com and send it to you

What is community?1. Locality2. Interest or shared purpose3. Sense of belonging: “community spirit”

“There is no power for change greater than a community discovering what it cares about.” ~ Margaret Wheatley

Source of image: rootedincommunity.org

Power in community“Power used to come largely through and from big institutions.Today power can and does come from connected individuals in community.When community invests in an idea, it co-owns its success.

Source of image: orton.org

Instead of trying to achieve scale all by ourselves, we have a new way to have scale. Scale can be in, with and through community.”

Nilofer Merchant

Why am I a radical?

TaskToday you will be working as a community with others on your table so it’s important to find out who is in your community.

Introduce yourself to others at your table. Tell a quick story that demonstrates why you chose to come to this course today.

Time allowed: 15 minutes for the whole table

The genesis of the School

20102012

NHS Change Day 2013

“A school for healthcare radicals”

Applying social movement

thinking to healthcare

improvement

“The School for Health and Care

Radicals”

“A one day school for organisational

radicals”

Applying community organising

principles to healthcare

improvement

Pledge today!http://changeday.nhs.uk

Source: @NHSChangeDay

The school is based on two kinds of learningTransactional learning Transformational learning

A “toolkit” of ideas & approaches

Learning through motivation, practice & feedback

Seeks to transfer useful knowledge

Seeks to transform beliefs & underlying assumptions

Learning event, presentations & materials

Experiential, interactive & action-based

Generates understanding of “what to do”

Generates increased capacity in “how to do it”

Source: Based on John Wenger https://medium.com/corporate-learning/3deb1bb2e865

What is happening in the world of change?

Source of image: from guardiansprayerwarrior.com

Emerging themes in change and transformation

Source: @HelenBevan

John Kotter: “Accelerate!”

• We won’t create big change through hierarchy on its own

• We need hierarchy AND network• Many change agents, not just the usual few • Changing our mindset

• From “have to” to “want to”• Head and heart, not just head

Source of image:www.slideshare.net/mexicanwave/champions-trolls-10-years-of-the-cipd-online-community

The Network Secrets of Great Change AgentsJulie Battilana &Tiziana Casciaro

1. As a change agent, my centrality in the informal network is more important than my position in the formal hierarchy

2. If you want to create small scale change, work through a cohesive network

If you want to create big change, create bridge networks between disconnected groups

is the new normal!

“By questioning existing ideas, by opening new fields for action, change

agents actually help organisations survive and adapt to the 21st Century.”

Céline Schillinger Image by neilperkin.typepad.com

ACROSS THE WORLD, THE CHANGE AGENT MOVEMENT IS EXPLODING!

@rebelsatworkrebelsatwork.com

@chagwwchangeagentsworldwide.com

@corprebelscorporaterebelsunited.com

@helenbevan #1000LivesPlusImage copyright: http://13c4.wordpress.com/2007/02/24/50-reasons-not-to-change/

#NHSChangeDay #SHCRchat@HelenBevan @BoelGare @JackieLynton #Quality 2014 #M5

Peter Fuda’s Transformational Change Agent framework

Skills and methods for creating change

Ability to make sense of, and reshape perceptions of ‘reality’

Personal characteristics and qualities

Peter Fuda’s Transformational Change Agent framework: my perspective

“Doing”• Where most change agents in health and care put most of their effort and emphasis

• What others typically judge us on

• What we often perceive we need to do to add value

• What most change and improvement courses focus on

Peter Fuda’s Transformational Change Agent framework: my perspective

“Seeing ” and “Being”• We can only do effective “doing” if we build on strong foundations of “seeing and being”

• Change begins with me• Hopeful futures, creative opportunities and potential

• Multiple lenses for change • See myself in the context of my higher purpose

“Being” as a health and care radical

Personal characteristics and qualities

What happens to heretics/radicals/rebels/mavericks

in organisations?

We need to be boatrockers!

• Walk the fine line between difference and fit, inside and outside, rock the boat but manage to stay in it

• Able to challenge the status quo when we see that there could be a better way

• Conform AND rebel• Capable of working with others to create success NOT a destructive troublemaker Source: Debra Meyerson

What are the risks for a boat rocker?

1. Our experiences of “being different” can be fundamentally disempowering. This can lead us to conform because we see no other choice we surrender a part of ourselves, and silence

our commitment, in order to survive2. leave the organisation

we cannot find a way to be true to our values and commitments and still survive

3. stridently challenge the status quo in a manner which is increasingly radical and self-defeating this just confirms what we already know – that

we don’t belong Source: adapted from Debra E Meyerson

#NHSChangeDay #SHCRchat@HelenBevan @BoelGare @JackieLynton #Quality 2014 #M5Source: Rebelsatwork.com

#NHSChangeDay #SHCRchat@HelenBevan @BoelGare @JackieLynton #Quality 2014 #M5Source of image: quote.lifehack.org

Source : Lois Kelly www.rebelsatwork.com

Sometimes other people see radicals/rebels as troublemakers

Discussion

• What are your insights around “rebels/radicals” and “troublemakers”?

• What moves people from being “rebel” to “troublemaker”?

• How do we protect against this?

Valuing radicals

• “New truths begin as heresies” (Huxley, defending Darwin’s theory of natural selection)

• Big things only happen in organisations because of heretics and radicals.

GALILEO DESCRIBES HIS DISCOVERIES TO THE CHURCH ESTABLISHMENT

#NHSChangeDay #SHCRchat

"There’s only one corner of the universe you can be certain of improving, and that’s your own self." Aldous Huxley

Source of image: timcoffeyart.wordpress.com

#NHSChangeDay #SHCRchat@HelenBevan @BoelGare @JackieLynton #Quality 2014 #M5Source: via @NeilWigg

History tells us that personal transformation comes before organisational or system transformation

If we want to play our role, we have to focus deeply on our own perspective and the ways

http://blogs.bmj.com/quality/2013/08/19/a-call-to-action-helen-bevans-blog-2/

we interact with and influence others. The more that we can unleash that powerful reservoir of energy for change, the more our influence and impact will grow.

Image from novamagazine.com

Change begins with me"I wanted to win minds. Now I win hearts. I used to find difficult doctors. Now I find doctors in difficulty”Dr Umesh Prabhu

Source: @WhoseShoes

1. Driven by conviction and values2. strong sense of “self-efficacy”

belief that I am personally able to create the change3. able to join forces with others to create action4. able to achieve small wins which create a sense

of hope, self-efficacy and confidence5. More likely to view obstacles as challenges to

overcome

Five things we know about successful boat rockers

Source: adapted from Debra E Meyerson

CHANGE

meBEGINS WITH

Self-efficacy

“If you think you can or think you

can't, you are right.”

Henry Ford

“The ability to act is tied to a belief that it is possible to do so”

Albert Bandura

There is a positive, significant relationship between the self-efficacy beliefs of a change agent and her/his ability to facilitate change and get good outcomes

Source of image:www.h3daily.com

What’s the difference between

self efficacyand

self esteem,self belief,

self-confidence?

What is the issue here?“permission” ?

(externally generated)or

Self efficacy ? (internally generated)

Brainstorm at the table

What are some ways that health and care radicals can build self-efficacy?

Building self-efficacy: some tactics1. Invest in your own change agent development

• create the conditions where success is more likely to happen

2. Create change one small step at a time3. Reframe your thinking:

• failed attempts are learning opportunities• uncertainty becomes curiousity

4. Make change (and learning cycles from change) routine rather than an exceptional activity5. Get social support6. Learn from the best7. Get people whose opinions you value to encourage you (mentor?)

“Being an effective Change Agent involves demonstrating what you

teach as much as pontificating from the mountaintops. Any behaviour we askothers to adopt, we must consistently

represent in our own work, and share the positive outcomes.”Bryce Williams

Working Out Loud

Source of image: leighellis.net

1. Driven by conviction and values2. strong sense of “self-efficacy”

belief that I am personally able to create the change

3. able to join forces with others to create action4. able to achieve small wins which create a sense of

hope, self-efficacy and confidence5. More likely to view obstacles as challenges to

overcome

Five things we know about successful boat rockers

Source: adapted from Debra E Meyerson

CHANGE

meBEGINS WITH

Source of image: outskirtsbattledome.wikispaces.com

The easiest way to thrive as an outlier

...is to avoid being oneSeth Goodin

“if you want to go fast, go alone. If you want to go far, go together.”African proverb quoted by Al Gore

Learning from social movement leaders

Call to Action

Source: @RobertVarnam

How do we create change at scale?

Source: Marshall Ganz

Shared understanding leads toAction

Narrativewhy?

Strategywhat?

What is strategy?

Strategy is the process of turning the RESOURCES you have into the POWER you need to win

the CHANGE you wantSource: Marshall Ganz

Resources to improve health and care

Economic resourcesdiminish with use• money• materials• technology

Natural resourcesgrow with use• relationships• commitment• community

Based on principles from Albert Hirschman, Against Parsimony

diminish grow

Framing … is the process by which leaders construct, articulate and put across their message in a powerful and compelling way in order to win people to their cause and call them to action.

Snow D A and Benford R D (1992)

What’s the financial incentive?

Who is performance managing?

What’s the project plan?

The reality“What the leader cares about (and typically bases at least 80% of his or her message to others on) does not tap into roughly 80% of the workforce’s primary motivators for putting extra energy into the change

programme”Scott Keller and Carolyn Aiken (2009)

The Inconvenient Truth about Change Management

Source of image: swedenbourg-openlearning.org.uk

“I have some Key Performance

Indicatorsfor you”

“I have a dream”

Leaders ask their staff to be ready for change, but do not engage enough in sensemaking........

Sensemaking is not done via marketing...or slogans but by emotional connection with employees

Ron Weil

How the world of work is shifting

• The organisation as a collective

• Leaders seek to build the allegiance of the workforce to the goals, culture and ethos of the organisation

• The network as a connective

• We share and identify with a deeper, extra-corporate work culture and the structure is subordinated to that

Source:stoweboyd.com Source of image: www.slideshare.net/mexicanwave/champions-trolls-10-years-of-the-cipd-online-community

If we want people to take action, we have to connect with their emotions through values

action

values

emotion

But not all emotions are equal.........

inertiaurgency

anger apathy

solidarity isolation

you can make a difference

Self-doubt

hope fear

Action motivatorsAction inhibitors

Effective framing: what do we need to do?

1. Tell a story2. Make it personal3. Be authentic4. Create a sense of “us” (and be clear who the “us”

is)5. Build in a call for urgent action

Creating our narrative

• Challenge: What was the challenge? Why was it a challenge?

• Choice: What were the choices? Why did you make the choice you did? Where did you get the courage or hope? How did it feel?

• Outcome: How did the outcome feel? Why did it feel that way? What do you want us to feel?

Vivid details

Talk to the person next to you

• Tell your story about why the change you are involved in now is so important to you

• Relate it to a personal experience

You have:• 2 minutes to prepare your story• 2 minutes each to tell your story

Talk to the person next to you

Have a further discussion• In terms of the people you want to get on board with your change project, what will create a sense of “us” rather than “us and them”?

• How could telling your story help create the “us”?

You have three minutes for further discussion as a pair

Talk to the rest of the table

What insight did you get from that exercise?

You have five minutes for a whole table discussion

How do we create a sense of “us” to build momentum for change?

Source of image: studentblognmaestics.blogspot.com

strong ties (cohesive)v.

weak ties (disconnected)

Source of image:brucemacvaresh.com

When we spread change through strong ties:

• we interact with “people like us”, with the same life experiences, beliefs and values

• Change is “peer to peer”; GP to GP, nurse to nurse, gynaecologist to gynaecologist

• Influence is spread through people who are strongly connected to each other, like and trust each other

When we spread change through strong ties:

• we interact with “people like us”, with the same life experiences, beliefs and values

IT WORKS BECAUSE: people are far more likely to be influenced to adopt new behaviours or ways of working from those with whom they are most strongly tied

The pros and cons of strong ties

Pros Cons

Strong and weak tiesWhen we seek to spread change

through strong ties:• we interact with “people like

us”, with the same life experiences, beliefs and values

When we seek to spread change through weak ties:

• we build bridges between groups and individuals who were previously different and separate

• we create relationships based not on pre-existing similarities but on common purpose and commitments that people make to each other to take action

• our aim is to mobilise all the resources in our organisation, system or community that can help achieve our goals

Why we need to build weak ties AS WELL AS strong ties

• Weak ties are more likely to lead to change at scale because they enable us to access more people with fewer barriers

• In situations of uncertainty, we have a tendency to revert to our strong tie relationships• yet the evidence tells us that weak ties are much more

important than strong ties when it comes to searching out resources in times of scarcity

• The most breakthrough innovations will come when we tap into our weak ties

• The most breakthrough innovations will come when we tap into our weak tiesHistory suggests that weak ties will probably give us the best

chance to deliver large scale improvements in a challenging timescale

Three components of a great narrative

• Diagnostic – what is the problem that we are addressing? What is the extent of the problem? What is the specific source or sources?

• Prognostic – what could the future look like? What is our “plan of attack” and our strategy for carrying out the plan?

• Motivational – why is this urgent? What is our call for action that connects with the motivational and emotional drivers of the audience?

Source: Benford and Snow

‘If people give to a cause, they expect a relationship, not a transaction.’

Nilofer Merchant

“A cynic, after all, is a passionate person who does not want to be disappointed again.”

Zander R and Zander B (2000) The art of possibility. Harvard Business School Press. As quoted by Steve Onyett

Who are your communities?

Source: Celine Schillinger http://weneedsocial.com/blog/2013/8/25/disrupted-disruptors-unite

• In your role: through relationships and social networks

• Through external social networks such as Twitter and LinkedIn

• Through communities of practice and learning groups

http://weneedsocial.com/blog/2013/8/25/disrupted-disruptors-unite

The most effective change agents:• don’t waste their time and energy blaming and complaining

• take calculated risks to achieve the outcomes they sought

Now is the time to plan steps to keep moving myself forward, with positive momentum, as a health and care radical

Three assumptions for health and care radicals

1. Assume that everyone has a noble intention.2. When people “resist” change is it more likely

to be a result of their interpersonal interaction with the change process than their innate character traits (“a bad change process not a difficult person”).

3. My role as a change agent is about alignment, not judgement.

Source of image:help.adobe.com

Being a great change agent is about knowing, doing, living and being improvement

Don’t boost self esteem

without boosting personal

knowledge and skills

“Being” as a health and care radical

CHANGEme

BEGINS WITH

• Living my conviction and values• Strong sense of “self-efficacy”

belief that I am personally able to create the change

• Shared purpose, not de facto purpose• Stepping outside my comfort zone• A “rebel” rather than a “troublemaker”• Learning not judging

Outwitted

He drew a circle that shut me out -Heretic, rebel, a thing to flout.But Love and I had the wit to win:We drew a circle that took him in.

Edward Markham

“Seeing” as a health and care radical

Ability to make sense of, and reshape perceptions of

‘reality’

‘En este muno traidorNo hay verdad ni mentira,Que todo esta en el color

Del cristal con que se mira’

In this world of many mazesThere is nothing false or true:All depends upon the hue

Of the glass through which one gazes(Sixteenth-century Spanish quatrain)

Seeing

“Seeing, looking, monitoring, listening, perceiving and especially the indefinite concept

of intuitive feeling ”Aubrey Jango

Have a table discussion:What are some of the different ways of “seeing” change?

What do we mean by resistance to change?

#NHSChangeDay #SHCRchat#NHSChangeDay #SHCRchat

Source of image: sport-fitness-advisor.com

Any force that stops or slows movement

Resistance

Employee resistance is the most common reason executives cite for the

failure of big organizational-change

effortsScott Keller and Colin Price

(2011), Beyond Performance: How Great Organizations Build Ultimate

Competitive Advantage Source of image: Businessconjunctions.com

Change can either challenge or

threaten us…….Your beliefs pave

your way to success or block you

Marsha SinetarSource of image:Creatememe.chucklesnetwork.com

Diagnostic and

dialogic approaches

to resistance to change

• Change is something that happens “out there” in the organisation or system

• Resistance is a force to overcome• Resistance prevents change• Change agents must diagnose, manage and/or

overcome resistance • Resisters may be otherwise known as “laggards”, “blockers”, “in denial”

Resistance: a “diagnostic” approach

Resistance to change

“The role of the change agent is to recognise the causes of resistance and address each one. If this is not done,

then the change will be much harder to implement successfully and may not

succeed at all”David Stonehouse

The change agent: the manager’s role in changeBritish Journal of Healthcare Management, Vol. 19, Iss. 9, 09 Sep 2013, pp 443 - 445

Diagnostic: the role of the change agent

• People make their own reality• Change results from transformational

conversations involving more and different people in change discussions altering how and which people engage with each other by stimulating different perspectives to shape how people think about things

• Resistance is an inevitable consequence of a complex change process (based on diversity)

• Resistance should be embraced and worked with

Resistance: a “dialogic” approach

1. Create the conditions for transformational conversations by asking questions that are focussed on future possibilities, by inviting diversity into the system, and by being welcoming

2. Creat e opportunities for everyone to express their views, spot opportunities and build on each other’s ideas

3. Create ways for people to reflect together to find meaning, understanding and shared purpose in the change

Source: Peggy Holman

Dialogic: the role of the change agent

“The most basic not-so-secret formula for building an innovation culture is pretty simple - embrace diversity and start to attract, retain and promote a diverse workforce that looks differently, works differently, dress differently, speaks differently and is inclusive of the full spectrum of human sexual orientation and gender identities. Do this before you start hiring consultants and rethinking your innovation process, there is no process that works without true diversity.”Idris Moore

Source of image: idsgn.org

Diversity is critical to innovation and change

“Leaders and organisations must let go of the idea that there is “one right way” and instead focus on creating a learning culture where people feel accepted, are comfortable contributing ideas, and actively seek to learn from each other”Diaz_Uda, Medina and Schill (2013)

Source of image:fineartamerica.com

Health and care radicals should be champions of diversity for change

In the context of “rolling with resistance”• What are the implications of embracing diversity of thought, experience and background in our change efforts?

• What skills and perspectives do health and care radicals need to work effectively with diverse teams for change?

Source of image:fineartamerica.com

Discussion

The effectiveness of change agents is not a matter of intention; it’s a matter of impact

• Helen’s intent was to give people quick solutions, help them do their work faster and get on to the next problem at hand

• However, her impact was that people did not know how to solve their own problems so that Helen’s style was impeding their development

Source: adapted from Intent vs. Impact: A Leadership Lesson by Claudia Busch LeeSource of image: thedigitalawards.com

Stop talkingAT ME

Start talkingTO ME Source of image: prepbeijing.com

• Build a trusting and supportive work environment

• Listen with an open heart and open mind• Commit to the change 100%• Seek common purpose and common interests

• Take time to build relationships• Be open with my intent• Take responsibility for my own actions

What should I do to manage intent and impact?

If your horse dies, get off itCherokee proverb

Source of image: fenwickgallery.co.uk

Have a discussion with others at your table:• How can I manage my intent and impact?

“Stages of change” Transtheoretical model of behaviour change

Prochaska, DiClemente & Norcross (1992)

The model is mostly used around health-related behaviours

• smoking cessation • exercise adoption• alcohol and drug use• weight control • fruit and vegetable intake• domestic violence• HIV prevention• use of sunscreens to prevent skin cancer • medication compliance • mammography screening

The model is mostly used around health-related behaviours

• smoking cessation • exercise adoption• alcohol and drug use• weight control • fruit and vegetable intake• domestic violence• HIV prevention• use of sunscreens to prevent skin cancer • medication compliance • mammography screening

It works for organisational and service change too!

“Stages of change” Smoking

I am not aware my smoking is a

problem – I have no intention to quit

I know my smoking is a problem – I

want to stop but no plans yet

I am making plans & changing things

I do in preparation.

I have stopped smoking!

I am continuing to not smoke.

I sometimes miss it – but I am still not

smoking

I am continuing to not smoke.

I sometimes miss it – but I am still not

smoking

“Stages of change” Transtheoretical model of behaviour change

• Which stage do most change activities in health and care focus on?

• Which stage are most people actually at?

Some questions

The reality of our change situation• Our tools are often not effective at the stage of change that most people we work with are at

• It’s hard to engage people in change• It’s hard to get people to make the changes we want them to make

• People get irritated, defensive, irrational• We feel powerless in our ability to lead or facilitate the change

90% of the tools available for health and care change agents are designed for the “action” stage

• Designed for Stage 4 – ACTION!

• Mandated it through targets

• Despite compelling case for change – people resisted it – no values connection

• People did the task and missed the point

Example - Surgical Checklist

• Lower our ambitions for improvement• Focus our energies on those who are already in the “action” stage

• Put negative labels on those who are not yet at the action stage such as “blocker” or “resister” or “laggard”

• Blame “the management” for not enforcing change

So what do we TEND to do?

The single biggest problem in communication is the illusion that it has taken

George Bernard Shaw

• Listen and understand appreciate the starting point elaborate interests

• Build meaning and conviction in the change• Roll with resistance (Singh)

Don’t argue against it Encourage elaboration of resistance

• What makes it so hard?• What would help?

• Build shared purpose

So what SHOULD we do?

• The focus should be on creating awareness for me of the need to change

• Remember the goal is not to make me (as a precontemplator) change immediately, but to help me move to contemplation

Example from the worksheet

• I am not thinking about changing my behaviours, actions or work processes

• The problem or issue is outside my frame of awareness or my perceived need

Focussing on Prochaska, DiClemente and Norcross’s Stages of Change model: • What stage of change are some of the key people that you need to influence for your change initiative at?

• What actions can you take to help them move to the next stage?

Reflection

“Seeing” as a health and care radical

• The big picture• Multiple perspectives• The positive intentions of others• Possibility of bad change processes rather than resistors, blockers and laggards

• Hopeful futures, creative opportunities and potential

• Multiple paradigms for change (eg, diagnostic and dialogic)

• See myself in the context of my higher purpose

“Doing” as a health and care radical

Skills and methods for creating change

Most large scale change doesn’t fullydeliver its objectives

Source: McKinsey Performance Transformation Survey, 3000 respondents to global, multi-industry survey

Gets anywhere near achieving the change and delivering the

benefits

Most large scale change doesn’t fullydeliver its objectives

Source: McKinsey Performance Transformation Survey, 3000 respondents to global, multi-industry survey

25%5% Delivers and

sustains the change

#NHSChangeDay #SHCRchat@HelenBevan @BoelGare @JackieLynton #Quality 2014 #M5Image from: @TheWorldStories

It is our contention that most change efforts are built upon the shaky foundation of five flawed assumptions; that change can be managed, that human beings are objective, that there are ‘X’ steps to change, that we have a neutral starting point for change, and that change, itself, is the goalPeter Fuda http://www.peterfuda.com/wp-content/themes/peterfuda-bootstrap/content/Why-Change-Efforts-Fail.pdf Source of image: Whatsthebigideascwartzy.blogspot.com

What happens to large scale change efforts in reality?

In order of frequency:1. the effort effectively “runs out of energy” and

simply fades away2. the change hits a plateau at some level and no

longer attracts new supporters3. the change becomes reasonably well established;

several levels across the system have changed to accommodate or support it in a sustainable way

Source: Leading Large Scale Change: a practical guide (2011), NHS Institute

Leaders as “signal generators”

“As a leader, think of yourself as a “signal generator” whose words and actions are constantly being scrutinised and interpreted, especially by those below you [in the hierarchy]”

“Signal generators reduce uncertainty and ambiguity about what is important and how to act”

Charles O’Reilly, Leaders in Difficult Times, 2009

Front line teams get inundated with high priority messages from leaders each day, making it difficult for them to know what to focus on

Increasing number of messages as information cascade through

the organisation

Source: adapted from http://businessjournal.gallup.com/content/162707/change-initiatives-fail-don.aspx

Front line teams get inundated with high priority messages from leaders each day, making it difficult for them to know what to focus on

Increasing number of messages as information cascade through

the organisation

Source: adapted from http://businessjournal.gallup.com/content/162707/change-initiatives-fail-don.aspx

Buy in from front line staff is critical for improvements in quality and safety . Don’t overload them

Buy in from front line staff is critical for improvements in quality and safety

Don’t overload themhttp

://healthaffairs.org/blog/2014/03/07/the-dangers-of-quality-improvement-overload-insights-from-the-field

Typically, around any change effort, there is an initial spike of tangible energy, and change, but when leadership loses interest, the momentum

of change slows down drastically.”Tara Paluck

Ten key principles of large scale change 1. Movement towards a new vision that is better and fundamentally

different from the status quo

2. Identification and communication of key themes that people can relate to and that will make a big difference

3. Multiples of things (‘lots of lots’)

4. Framing the issues in ways that engage and mobilise the imagination, energy and will of a large number of diverse stakeholders in order to create a shift in the balance of power and distribute the leadership

5. Mutually reinforcing change across multiple processes/subsystems

6. Continually refreshing the story and attracting new, active supporters

7. Emergent planning and design, based on monitoring progress and adapting as you go

8. Many people contribute to the leadership of change, beyond organisational boundaries

9. Transforming mindsets, leading to inherently sustainable change

10. Maintaining and refreshing the leaders’ energy over the long haul

Ten key principles of large scale change

Intrinsic motivationPeople engage in the activity for the pleasure and satisfaction of doing it

Invokes many positive behaviours

Extrinsic motivationPeople engage in the activity for the rewards or avoiding punishment

Any external influence is referred to as extrinsic motivation

Source: http://www.slideshare.net/JeremyStephens103/coaches-as-extrinsic-motivators-and-supporter-of-intrinsic-development

Transformation is not a matter of intent.........it is a matter of alignmentPeter Fuda

You get the best effort from others not by lighting a fire beneath them, but by

building a fire withinBob Nelson

“Take your passion and

make it happen”

Source of image: www.zeelandtheaters.nl

Discussion

Reflecting on your change process:• how have you built both intrinsic and extrinsic motivators of change into your efforts?

• How have you managed the tension between the two?

• Any advice for other change agents on how to align intrinsic and extrinsic motivators?

What happens to large scale change efforts in reality?

In order of frequency:1. the effort effectively “runs out of energy” and

simply fades away2. the change hits a plateau at some level and no

longer attracts new supporters3. the change becomes reasonably well established;

several levels across the system have changed to accommodate or support it in a sustainable way

Source: Leading Large Scale Change: a practical guide (2011), NHS Institute

Research shows that more than almost any other factor affecting an

organisation, organisational energy can lead to either a wellspring of corporate

vitality or the destruction of its very core

Source: Bruch and Vogel

Bruch and Vogel researchOrganisations with HIGH productive energy scored higher on:• overall performance - 14% higher• productivity – 17%• efficiency – 14%• customer satisfaction – 6%• customer loyalty – 12%

the capacity and drive of a team, organisation or system to act and make the

difference necessary to

achieve its goals

Psychological

Physical

Spiritual

Social Intellectual

Energy for change is:

Five energies for change Energy DefinitionSocial energy of personal engagement, relationships and connections

between people. It’s where people feel a sense of “us and us” rather than “us and them”

Spiritual energy of commitment to a common vision for the future, driven by shared values and a higher purpose. It gives people the confidence to move towards a different future that is more compelling than the status quo

Psychological

energy of courage, resilience and feeling safe to do things differently. It involves feeling supported to make a change and trust in leadership and direction

Physical energy of action, getting things done and making progress. It is the flexible, responsive drive to make things happen

Intellectual

energy of analysis, planning and thinking. It involves gaining insight as well as planning and supporting processes, evaluation, and arguing a case on the basis of logic/ evidence

High and low ends of each energy domain

Low High

Social isolated solidarity

Spiritual uncommitted higher purpose

Psychological risky safe

Physical fatigue vitality

Intellectual Illogical reason

• Are particular energy domains more dominant than others for our team at the moment?

• Is this the optimal energy profile to help us achieve our improvement goals?

Energy for change profileSocial

Spiritual

PsychologicalPhysical

Intellectual

Social

Spiritual

Intellectual

Team 1: what’s your assessment of their energy for change?

Social

Spiritual

Intellectual

Team 1: what’s your assessment of their energy for change? This energy profile is

characterised by an environment that has harnessed people’s interest and momentum for change, but which has failed to engage people fully. This imbalance results in their feeling some uncertainty regarding how they can contribute fully to the change, and therefore a sense of risk and lack of hope for the future. We can build energy by building team solidarity and developing shared purpose

Social

Spiritual

Intellectual

Social

Spiritual

Intellectual

This energy profile shows strong connections between people, a true sense of solidarity, which gives them enough hope for the future, but this energy is undirected, because the rational argument and shared purpose has not been agreed. We can build energy by agreeing shared goals for change and using systematic approaches to thinking through and planning the change

There has never been a time in the history of healthcare when this advice

has been more pertinent

“Leadership is not about making clever decisions and doing bigger deals. It is

about helping release the positive energy that exists naturally within people”

Henry Mintzberg

“You can’t impose anything on anyone and expect them

to be committed to it”Edgar Schein, Professor Emeritus

MIT Sloan School

#NHSChangeDay #SHCRchat@HelenBevan @BoelGare @JackieLynton #Quality 2014 #M5 Source: Helen Bevan

Compliance

States a minimum performance standard that everyone must achieve

Uses hierarchy, systems and standard procedures for co-ordination and control

Threat of penalties/ sanctions/ shame creates momentum for delivery

What is our approach to change?Commitment

States a collective goal that everyone can aspire to

Based on shared goals, values and sense of purpose for co-ordination and control

Commitment to a common purpose creates energy for delivery

Shared purpose aligns.....

Shared purpose allows many communities to engage with us without us having to invest resourcesin controlling their actions Nilofer Merchant

We know that ...

• Shared purpose is a common thread in successful change programmes*

• Organisations and change initiatives with strong shared purpose consistently outperform those without it.**

*What makes change successful in the NHS? Gifford et al 2012 (Roffey Park Institute)

**Management Agenda 2013 Boury et al (Roffey Park Institute)

A 3-word concept

[Shared] purpose goes way deeper than vision and mission; it goes right into your gut and taps some part of your primal self. I believe that if you can bring people with similar primal-purposes together and get them all marching in the same direction,

amazing things can be achieved.Seth Carguilo

Avoiding “de facto” purpose• What leaders pay attention to matters to staff, and consequently

staff pay attention to that too• Shared purpose can easily be displaced by a “de facto” purpose:

hitting a target reducing costs reducing length of stay eliminating waste completing activities within a timescale complying with an inspection regime

• If purpose isn’t explicit and shared, then it is very easy for something else to become a de facto purpose in the minds of the workforce

Source: Delivering Public Services That Work: The Vanguard Method in the Public Sector

#NHSChangeDay #SHCRchat@HelenBevan @BoelGare @JackieLynton #Quality 2014 #M5@SimonJGuilfoyle Police Inspector and systems thinker

Purpose

Obfuscation O-

@SimonJGuilfoyle Police Inspector and systems thinker

Police

Education

Healthcare

....the last era of management was about how much performance we could extract from people .....the next is all about how much humanity we can inspireDov Seidman

“Doing” as a health and care radical

• Create the conditions where everyone can contribute and do their best

• Join forces with others to create action• Achieve small wins which create a sense of hope, self-efficacy and confidence

• Appeal to both the head (logic/planning/data) and the heart (shared values/purpose, framing, relationships)

• Make change (and learning cycles from change) routine rather than an exceptional activity

• Use models, theories and frameworks effectively

‘I do not think you can really deal with change without a person asking real

questions about who they are and how they belong in the world’

David Whyte, The Heart Aroused 1994Source of image: fistfuloftalent.com

We have a choice“This is the true joy of life, the being used up for a purpose recognised by yourself as a mighty one,

being a force of nature instead of a feverish, selfish little clot of ailments and grievances, complaining that the world will not devote itself to making you

happy.”

George Bernard Shaw

School for Health and Care Radicals; International Forum on Quality and Safety in Healthcare 2014

Healthcare

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