Inspiring change in the NHS: the five frames

Inspiring Change in the NHS:Introducing the Five Frames

This document is intended to be updated regularly in order to ensure it is as helpful as possible. This is Version 1, published on 22 May 2009.If you have feedback on how it can be improved or if you have a query or would like further information, please contact:Annette Neath at [email protected]

Included within this document is reference to specific tools, including, but not limited to, the Five Frames and the Organisational Health Index (“Tools”). All intellectual property rights, including copyright, in and to the Tools, are the sole property of McKinsey & Company. The Tools may be used internally by the staff of the NHS, but no other person may use, reproduce, disclose or distribute the Tools without McKinsey & Company’s express prior written consent.

Contents

Executive Summary 1 Delivering High Quality Care for All 3The Five Frames 6 – Introduction – Quick reference – Summaries of the Five Frames

Appendix: Examples, tools, evidence, 16 tips and tricks

� | Inspiring Change in the NHS: Introducing the Five Frames

Executive Summary

High Quality Care for All (HQCfA) has set a profound challenge to the NHS. Achieving the vision set forth in HQCfA will require fundamental changes in our thinking and in how we work, in our teams and across the entire system. The current economic climate and our need to plan for the next Comprehensive Spending Review increase the imperative for change.

In response to the challenges set forth, David Nicholson consulted experts within and outside the NHS on how to achieve the type of sustainable, large scale changes that are clearly required. The Four Principles (co-production, subsidiarity, system alignment and clinical engagement) are the result of this initial consultation. They represent the guidelines for the new ways we should work in order to bring about the vision laid out in High Quality Care for All. The Five Frames provide a way to realise these new ways of working. They are a powerful model of change, representing five important areas of consideration for leaders in the NHS.

The NHS Management Board members recognise that this change must start with them. They have been working through the Five Frames to identify what they need to change in how they work, and what they can do to support change across the system. This is not to suggest that the frames are mandatory or an alternative to on-going activity. NHS leaders who have already used the Five Frames have built them into their existing change approaches to gain an additional perspective or more robust change plans.

This document introduces NHS leaders to the Five Frames, as they consider what changes may be needed in their parts of the system, and how they can achieve them.

“ Strategies and processes alone are not sufficient to drive the degree of change we are seeking…the NHS should focus on tackling the behaviours and cultures in the system that stand in the way of moving forward on quality.”

— David Nicholson, Annual Report 2009

The Five Frames are:

Performance & Health: Change is not just about delivering performance today. It is also about creating ‘healthy’ organisations and systems which will deliver performance tomorrow and the day after.

The Discovery Process: Creating deep, sustainable change is not just about creating an excellent strategy or about redesigning delivery systems and processes. It is also about changing the mindsets which underlie behaviours and outcomes.

The Influence Model: When we plan actions to bring about the desired changes in mindsets and behaviours in our organisations, we need to make sure that we create a wide range of initiatives that cover a broad perspective of change, rather than concentrating on a single ‘type’ of intervention that will not deliver wide scale change.

Change Architecture: In designing a change strategy, particularly in a complex system, we need to plan carefully to make sure that the initiatives are well-sequenced, occur at the right place in the organisation, engage stakeholders and are well-understood.

The Benefits Hierarchy: Measuring the success of change interventions is vital. As well as ensuring that initiatives are on schedule and milestones are met, and measuring performance as the outcome, we need to measure organisational and system health and make sure it is improving.

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Inspiring Change in the NHS: Introducing the Five Frames | �

In this document, we present the Five Frames as a logical set for thinking about change. However, as other NHS leaders have done, you can choose to work with all five, or with just one or two frames and fit them into your existing approach to change.

How to use this document• Audience:

The NHS leadership community – those who lead change in NHS organisations and those who partner with other organisations to lead change in the wider health system.

• Structure: A summary of each frame is provided, together with an appendix which provides examples, tools, evidence, tips and tricks.

To learn more:This document is ‘work in progress’. We will make further materials available and offer learning opportunities. In the spirit of co-production, we would very much like to hear from you on what would be useful. You can contact Annette Neath at [email protected] if you have a query, want further information, or would like to suggest support materials for use with your team.


Delivering High Quality Care for AllWhat’s the challenge?High Quality Care for All (HQCfA) has set out a profound challenge to the NHS to achieve significant gains in population health, quality and productivity through innovation and to address variation in the system. The current economic climate and our need to plan for the next Comprehensive Spending Review increase the imperative for change.

HQCfA sets out ‘what’ we need to do. The challenge is ‘how’ to do it. History suggests that the process of turning strategic goals into implementation strategies that go on to deliver real results for our populations and patients is likely to be the weakest link in the chain. To achieve the breakthroughs we seek in quality and efficiency, we need to focus NHS change efforts not just on new strategies and working practices but on new ways of thinking.

What’s the relevance of organisational and system health to this challenge?One of the biggest shifts required in our thinking, and part of the ‘radical transformation’ called for, centres on how we think about performance and how to manage it. In recent years, we have focused much of our performance management effort on immediate payoffs by achieving short-term targets. However, evidence suggests that this might be a risky strategy longer term. It can stifle ambition, and even incapacitate organisations and systems like ours, leaving them unable to achieve more than specific deadlines or targets.

Across the globe, leading-edge organisations and systems are adopting a dual focus on performance and the health of the organisation and system. Organisational and system health is about having the properties and qualities today that create the conditions for high performance tomorrow. Healthy organisations typically have cultures which promote trust, openness and engagement and enable continuous learning and improvement. Everyone is pulling in the same direction where it matters. There is a ‘can do’ culture, supported by effective working processes. A healthy organisation or system can absorb shocks and knocks from the wider system it operates in and can adapt in response to a changed environment.

“ Achieving this vision of quality requires a radical transformation across the entire system. Change on this scale, in a system as large and complex as the NHS, has not been achieved before.”

— David Nicholson, Annual Report 2009


70

Employees resistant to change

Management behaviour not supportive of change

Inadequate resources or budget

Other obstacles

39

33

14

14

% of efforts failing to achieve target impact Factors contributing to failure

>70% due to cultural factors

Figure 1 - 70% of change programmes fail, and 70% of those that fail do so because cultural barriers impede successful implementation

The evidence base on transformational change suggests that only one in three large transformation programmes is considered ‘successful’. Only one in sixteen is considered to be ‘extremely successful’. This evidence shows that by focusing on organisational health as well as performance, we can create the best conditions for change in the NHS. The Five Frames, and particularly the starting point of a focus on organisational health, force our attention to issues of culture, mindsets and behaviour. Evidence suggests that as many as 70% of change programmes that fail do so because leaders don’t address the cultural barriers that impede successful implementation.

Successfully achieving this sort of large scale transformation is particularly challenging because the NHS is a complex system, made up of many different types of organisations. For us, the health of the entire system is as critical as the health of the individual organisations.


What’s the relevance of the Five Frames to this, and how do they fit with what we’ve seen already?In response to the challenges set forth in High Quality Care for All, David Nicholson consulted experts within and outside the NHS on how to achieve the type of sustainable, large scale changes that are clearly required. The Four Principles are the result of this initial consultation. They represent the guidelines for how we should work in the NHS called for in High Quality Care for All.

The Five Frames provide a way to realise this new way of working. They are a powerful model of change, representing five important areas of consideration for leaders in the NHS. Within this model, a variety of existing tools can be used. These include tools such as Plan, Do, Study, Act cycles, and Lean Improvement methodologies. In addition, other models for change are currently used in the NHS, such as Vision-Method-Expectation, which can be used in tandem with some or all of the frames. Finally, the NHS Constitution, and in particular the patient and staff pledges and values within it, should provide guidance for all change activities considered.

What has the NHS Management Board done?The Board recognises that it must embrace the change that has been called for, and that any change must start with itself. Rather than telling others to change, the Board is first changing its own mindsets and behaviours. To this end, it has been working through the Five Frames to:

Identify the Board mindsets and behaviours that impede change, and consider the mindsets needed for the future; Understand and define the role it can play in leading and supporting large scale change; Develop a plan of action that reflects the new way of working.

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The Four Principles of Change: Co-production, subsidiarity, system alignment and clinical engagement.


What are they? The Five Frames represent five key areas of consideration for any leader taking a team or organisation on a journey of cultural change.

The Five Frames are used when designing and managing change, but can also be an intervention in themselves. Whilst the ultimate result of using the Five Frames should be a well-crafted programme for change, the very act of using them can be a powerful catalyst for teams to change their own behaviours.

The frames are the grounding for a large-scale change strategy. They do not represent most of the work, which really starts to happen towards the end of this process.

The Five Frames

The Five Frames• Performance & Health:

Change is not just about delivering performance today. It is also about creating ‘healthy’ organisations and systems which will deliver performance tomorrow and the day after.

• The Discovery Process: Creating deep, sustainable change is not just about creating an excellent strategy or about redesigning delivery systems and processes. It is also about changing the mindsets which underlie behaviours and outcomes.

• The Influence Model: When we plan actions to bring about the desired changes in mindsets and behaviours in our organisations, we need to make sure that we create a wide range of initiatives that cover a broad perspective of change, rather than concentrating on a small number of changes that will not deliver wide scale change.

• Change Architecture: In designing a change strategy, particularly in a complex system, we need to plan carefully to make sure that the initiatives are well-sequenced, occur at the right place in the organisation, engage stakeholders and are well-understood.

• The Benefits Hierarchy: Measuring the success of change interventions is vital. As well as ensuring that initiatives are on schedule and milestones are met, and measuring performance as the outcome, we need to measure organisational and system health and make sure it is improving.

FramesCurrent use in the NHS

Evidence and experience

Performance and Health Low

The Discovery Process Medium

The Influence Model Medium

Change Architecture Low

The Benefits Hierarchy Minimal

Figure 2 - The Five Frames are currently at different levels of development and exposure within the NHS

� | Building a Healthy NHS: Introducing the Five Frames

Central Manchester University Hospitals Foundation Trust

The Trust has recently embarked on a large scale change programme, in which the senior team is shifting a strongly performance-driven focus more towards a focus on quality, particularly as it relates to patient experience, staff engagement and patient safety.

The team recognised that the current performance management systems would not go far enough in winning over ‘hearts and minds’ to the quality improvements they aspire to.

In an attempt to address this, the team was one of the first NHS Trusts to use the Discovery Process, with its focus on uncovering and ultimately shifting underlying mindsets. A culture survey was first undertaken by the team, which identified various aspects of their culture which they wanted to keep, others they wanted to move away from and a new set which they aspired to bring in.

After some preliminary work with a facilitator from the NHS Institute, Directors and Assistant Directors, including Clinical and Finance Directors, took part in two half-day workshops. The two goals of the workshops were: i) Explore the existing mindsets and how these needed to change; ii) Look at the existing Trust culture and determine

what would help and what would hinder the success of the change programme.

An example ‘from’ mindset uncovered was “Our workforce is large and complex”, for which a new ‘to’ mindset was agreed – “We value all of our staff, everyone counts.”

On the back of the Discovery Process work, the Quality strategy has undergone several iterations. Workforce engagement and participation is now central to its delivery. The strategy has only recently been launched, but the team is confident that the strategy is much more authentic and will have greater impact and resonance as a result of the mindset work they have done.

“�The�Discovery�Process�gave�us�permission�to�think�differently�about�challenging�issues�and�behaviours,�it�allowed�us�to�come�out�of�fixed�mindsets.�Emotional�intelligence�matters.�It�can�result�in�real�step�changes.”

— Helen Cameron, Assistant Director of Nursing,

Central Manchester NHS Foundation Trust

Why are they worth considering? The Five Frames are based upon detailed evidence, drawn from a broad range of studies from the social sciences and business. The frames can help improve the design and leadership of your change strategy in a number of ways:

They can help you find the best changes to make in order to deliver your strategy; They provide structure and support for you to have conversations with clinical and managerial leaders, improving the alignment of your team;

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They help identify where you as a leader can be directly influential, and where you need to work through others; They help make sure that your organisation is solving the right problems, by finding the deeper drivers and barriers to success; They build momentum right from the start, by visibly having leaders work in a new way together.

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“ Using the framework helped depersonalise and thus address complex and challenging issues”

“ The process helped focus on the value of the culture changes aspired to”


The process involves paying attention to getting alignment and getting leaders walking the walk. This can feel like slowing things down at first. What it does, however, is radically increase your chances of success.

The field of organisational change and the links between culture and performance are areas where empirical evidence has traditionally been scarce. The Five Frames are based on evidence where available – some of this is laid out in the appendix – though the evidence is sometimes from the private sector.

We are committed to broadening and deepening the evidence base through the work that we do on change within the NHS, and in particular to making sure that the empirical footing of our approaches to change is increasingly sound.

How might the Five Frames be used?Ideally, you would want teams at different levels in your system to use the Five Frames in their own way, identifying changes that are right for their aspirations, but that are aligned to organisational goals. For instance, a Chief Executive and senior team might identify the changes which they want to make and the initiatives which they should sponsor to support change throughout their organisation. At the same time, the Chronic Disease team might identify their own, possibly different, changes which they would like to make and a corresponding set of actions or initiatives. This would of course be more time-consuming than mandating changes from the executive team. However, done well, it would have the advantage of using the journey through the frames as a powerful catalyst for change in itself.

Going through the approach rigorously requires time. This provides a great opportunity for teams to explore and do real work together, rather than transacting regular business in the usual way. The experience (the ‘how’) is as important as the plans created (the ‘what’).

National Leadership Leads Team

“�The�Five�Frames�offer�a�good�structure�and�process�to�think�about�organisational�culture�change.�They�present�a�coherent�package�around�changing�mindsets,�and�this�is�what�will�really�help�the�NHS�transform�to�make�quality�our�organising�principle.�Developing�a�new�mindset�and�role-modelling�different�leadership�behaviours�will�help�us�to�build�healthy�organisations.�The�frames�provide�a�new�rigour�and�approach�to�complex�transformational�change�and�tie�in�well�with�the�talent�and�leadership�planning�process.”

— Caroline Wigley, West Midlands SHA,

Leadership Leads Programme

Academy for Large Scale Change

The Academy for Large Scale Change supports national and regional leaders in the delivery of strategic, population-level transformational change. Approximately 70 senior leaders from SHAs, DH and NHS Institute for Innovation and Improvement are members of the Academy.

In January 2009 the members were introduced to the Five Frames and

recognised immediate synergies with current change frameworks and the Vision, Methods, Expectations model. The Academy is mapping its thematic programmes across the Five Frames. This ensures that the work of the Academy faculty is closely attuned with the emerging Five Frames, identifying opportunities for stronger integration and co-ordination.


Is this a credible approach?Yes – the Five Frames incorporate valuable progress in the social sciences over the past decade as well as rich empirical evidence. For example, there is clear evidence that using the principles outlined in the Change Architecture frame can dramatically increase the chances of a change strategy being successful.

Is this being used anywhere outside the NHS Management Board?Yes – a significant number of NHS organisations have used different frames in the past two to three years. Most of the current application of the overall Five Frames framework is at national or regional level. For instance a number of SHAs are taking their leadership teams through the Five Frames, and a number of regional and national groups have now seen the concepts and begun working with them (e.g., the Academy for Large-Scale Change, and the SHA Leadership Leads). However, the approach has application at all levels of the health system.

How quickly should I expect to see performance improve as a result of my cultural change strategy?This depends on a variety of factors such as the scale of your organisation, the amount of leadership attention you devote, the resources you make available to support it and how much capability already exists in your organisation for making change. A specific team within an NHS organisation, for example, might see real improvements within weeks. A small trust might see improvements in their performance in six months. For a larger, more complex organisation or a system, small improvements might only be seen after a year or more.

Is there further support available if my team and I want to learn more?Yes – the Institute wants to hear back from you on the type of support you would like. We want to work with the chief executive community and others to develop the best support we can. We will make further materials and support activities available. Please email [email protected] with any queries or suggestions.

How do the Five Frames fit with other change models and approaches, such as the Four Principles of Change?The frames work best when considered for your own context, building on and adding to what you are doing already. For example, a PCT that has embarked on a Lean transformation strategy for urgent care may use the frames to think about the ‘health’ of the urgent care system, the mindsets that are creating variation in the current system and the dimensions of influence that are needed to transform the system. Or a Foundation Trust, which has adopted the Vision, Method, Expectations (VME) framework (recommended as the leadership for change approach in High Quality Care for All), may find that the frames are a powerful tool for translating the VME model into action.

The Four Principles of Change are core to at least two of the frames. The Four Principles should guide what initiatives are planned, how they are planned and who should lead them.

Some questions about the Five Frames

The Five Frames incorporate valuable progress in the social sciences over the past decade as well as rich empirical evidence.

Inspiring Change in the NHS: Introducing the Five Frames | �0

Performance & Health

The Discovery Process

The Influence Model

Change Architecture

Benefits Hierarchy

Why is it important?

Ensures the ‘change energy’ is focused on what needs improving. Can provide ‘hard’ facts behind ‘soft’ issues.

Only by finding and changing the right mindsets can behaviours, and thus performance, be changed sustainably.

Creating this balanced approach, which uses four categories of influence, will dramatically increase the chances of achieving lasting change.

A programme which is clearly structured is easier to run, track and communicate. Any successful change programme must maintain buy-in and energy.

By measuring project deliverables, behavioural changes and health outcomes, where possible, we can tweak the change programme as we go.

What is this about?

Agreeing the aspirations for your organisation. Determining what aspects of your organisation’s health need to be strengthened to deliver this aspiration.

Identifying the desired changes in behaviour and changes in mindsets which drive these changes in behaviour.

Generating a set of self-reinforcing initiatives for the change process which balance the focus on the individual with a focus on the working environment.

Designing the implementation of the change process so that it is well structured and coherent, and maintains the energy required for change past the first few months.

Finding and implementing the best metrics to track the success of the change efforts and using this feedback to constantly readjust implementation.

How do we do it?

Variety of strategic documents as inputs. Strategy workshops, top team interviews, organisational diagnostics, focus groups.

A structured process involving a series of questions and explorations for the team. Typically requires a series of workshops.

Use workshops to brainstorm and then prioritise a set of balanced initiatives around the four categories of influence.

Cluster the initiatives into major themes, forming a main message. Prioritise initiatives according to impact and ease of implementation. Find the quick wins.

Work your way up the benefits pyramid, trying to find solid metrics as high up as possible. Track these during implementation.

Quick reference

How does this fit with other NHS methods, tools and initiatives?

HQCfA and the NHS Constitution should be used as inputs to setting the aspirations.

The Vision-Method-Expectations framework is complementary to this frame. NHS values should be used as a check for proposed changes.

Existing initiatives can be allocated to one of the four areas of the Influence Model – doing so will reveal if there is an approach too favoured or a ‘blind spot’.

The Four Principles of Change are key to architecting a successful change strategy.

Existing data sources such as the staff survey for SHAs could be used to track performance.

�� | Inspiring Change in the NHS: Introducing the Five Frames

Performance and Health(The ‘And’)

A balanced focus on both performance and health is necessary for longer term delivery. A thorough diagnosis of organisational and system health can help focus change efforts.

Too much focus on either performance or organisational health (the ability to deliver performance in the future) is problematic, though most organisations tend to focus on performance at the expense of health. There is now compelling empirical evidence from the private sector showing a powerful link between performance and organisational health. This frame seeks to address this balance, and to ensure that any new focus on health targets the aspects of health which are most critical to delivering against your aspirations.

The two big steps which might be covered in this frame are:

Lay out the aspirations for your organisation. This might draw from a variety of areas such as existing strategy and vision documents, the environmental context and the preferences of the team. There are some real choices to be made here, as excelling at everything is not possible.

1.

frame 1

Summaries of the Five Frames

Diagnose your organisation’s health. A diagnostic might include interviews, surveys, focus groups and workshops.

Comparing the ideal health to deliver the aspirations in step one with the actual health uncovered in step two should highlight current gaps. These can provide the focus for change and can act as inputs to the Discovery Process.

A fact-base is useful, as there is often a serious disconnect between how healthy an executive team believes its organisation is, and how healthy the rest of the organisation believes it is

There are of course many ways to think about organisational health, as well as a number of tools available to help with the diagnosis. The NHS Institute for Innovation and Improvement has commissioned a literature review on different approaches and frameworks for organisational health. A framework and corresponding diagnostic tool developed by McKinsey & Co., and now being used in some parts of the NHS, is provided in the appendix as an example of one approach.

2.

Likelihood that business achieves above-median financial performance%

31

48

68

2x

More than twice as likely tooutperform peers

Organisational health quartile

Bottom

Top

Middle

Figure 3 - In the private sector a strong link between performance and organisational health has been established

Tips & tricks

• Small, gradual changes are less easy to make and sustain than big ones! Create an aspiration around performance and health, which is ambitious, bold, and inspiring

• You always get more of what you ask for! In workshops use the method of Appreciative Inquiry to identify what works well and leverage pockets of strength in a change strategy

• Health needs to be understood at multiple levels! The organisation needs to be healthy, but so too does the system in which the organisation exists, and any ‘tribes’ within the organisation

Inspiring Change in the NHS: Introducing the Five Frames | ��

The Discovery Process(The ‘Horseshoe’)

frame 2

The Discovery Process is a way for leaders to dig below the surface to identify deeper barriers to and enablers of change at a cultural level.

One challenge for cultural change programmes is finding the most critical factors that influence how people work. The Discovery Process is a tool which helps teams identify a small number of critical changes which should drive new outcomes.

The process starts with the team considering the desired shifts in outcomes they would like to see. The team then works its way around the Horseshoe, systematically uncovering the shifts in behaviours and mindsets required to realise the ultimate changes in outcomes.

The two big steps which might be covered in this frame are:

Uncover the from–to’s: This involves facilitating a series of conversations, which can be one-to-ones or in groups, where you help people to systematically lay out what they see today and what they want to see tomorrow. Ideally, this should be done following an assessment of organisational health (frame 1) so that the mindsets reflect the changes that the organisations need to make.

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Probe for the enablers of the from-to’s: This involves probing to understand the ‘why’ that underlies the current state and the future states. Uncovering these will inform your choice of interventions, as well as ensuring that you are solving the right problem.

A significant side benefit of this process is that it heightens leaders’ own self-awareness and commitment to change. This is an example of how the Five Frames approach can be viewed both as a rigorous planning process and a powerful change intervention in itself.

The ‘Horseshoe’ illustrates both the theory and the process itself (see figure below). Mindsets drive practices which in turn drive outcomes. A fundamental change in desired outcomes thus may necessitate fundamental changes in practices and thus mindsets.

2.

Tips & tricks

• Probing for the root causes of behaviour is difficult and can be uncomfortable! Use an experienced, impartial facilitator for the workshops

• The most powerful change themes often have their origin in a dilemma! They are about shifting from the belief that you can either do one thing or the other to believing in being able to do both at the same time (e.g. reducing cost and increasing patient satisfaction)

“I’ll be seen as dedicated if I go into the office when I’m obviously sneezing”

“I’m so busy…I can’t take time off”

“I am valued for my work, not for the hours I work”

“The long-term is more important than the short-term”

Staff stay home when they are infectious

Staff visibly praised for judgement

IT set up well for home working

Colds are contained as much as possible

People come to the office with streaming colds

Outcomes

Practices

Mindsets

Outcomes

Practices

Mindsets

Current Desired

Colds are spreading like wildfire at work New strategic

direction

Culture change

Process improvements

Figure 4 - A possible slice of the Discovery Process in healthcare


The Influence Model(The ‘Jigsaw’)

frame 3

In planning the set of initiatives for your change strategy, it is important to use a range of influencing techniques, and not just rely on a favourite approach. You are much more likely to achieve large scale change if you plan a set of interventions that complement each other.

The Influence Model, drawing on the social sciences and extensive empirical evidence, reflects the four ‘categories’ of influence which any change process should address. By designing a balanced set of initiatives across the four influence categories, the activities support change directly and indirectly via communications, training and changes to the working environment.

The four areas covered by the influence model are:

Fostering understanding and conviction “ …I know what is expected of me, I agree with it, and it is meaningful”

Reinforcing with formal mechanisms “ …The structures, processes and systems reinforce the change in behaviour I am being asked to make”

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Developing talent and skills “… I have the skills, capabilities

and opportunities to behave in the new way”

Role-modelling “… I see leaders, peers

and reports behaving in the new way”

In many situations, there is over-reliance on two or even only one favoured area of the Influence Model to try and bring about change. Within the NHS reform strategy, we have probably over-relied on ‘formal mechanisms’ and need to do more on the other three areas of influence. Relying purely on financial incentives, for example, can often be less effective than a more holistic change strategy – or even counter-productive.

The creation of the ‘balanced’ set of initiatives is typically achieved via one or more workshops. When this set of initiatives is agreed, it can also be helpful to check how each one maps to the four categories of influence, arranging the interventions around the jigsaw (see the figure below for an example).

3.

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Role- modelling

Understand-ing and conviction

Skills required for change

Reinforcement mechanisms

4

23 • Embrace regulators more firmly as part of the system

• Create and embed SHA Assurance as a developmental process

• Develop and deliver quality strategy

• Communicate and engage

• Embed the Four Principles of Change in the centre

• Create greater coherence of purpose at the MB

Mobilise change agentsCreate strong common purpose amongst the Top 1000Nurture innovation and best practice transfer through appreciation and celebration

Develop leadership across the whole systemFind opportunities to reduce costOrganisational and System Health Metrics

1

Figure 5 - How the NHS Management Board used the Influence Model to design 12 initiatives that support change

Tips & tricks

• Fear can only motivate temporary change! For change to be sustainable, leaders must engage the organisation with a vivid, meaningful and exciting vision of the future

• Relying on one part of the Influence Model can be counter-productive! For example, top talent will only perform to its full potential in an organisation with strong social networks – without the supportive environment, top talent dramatically under-performs

• Money is the most expensive way to motivate people! Non-financial incentives can be not only cheaper but also more powerful than money


Change Architecture(The ‘Waves’)

Structuring the change strategy around a small set of themes will make implementation easier and more successful. Sequencing initiatives in order to generate and then maintain the energy for change is critical.

The Four Principles of Change in the NHS (co-production, subsidiarity, alignment and clinical engagement) are particularly important when it comes to creating the structure of the change initiative. We call this process the ‘Change Architecture’: turning the list of agreed interventions into a sequenced and prioritised plan of activities.

This plays out in a number of ways:

1. Decide where in the organisation the initiative should be led. The principles of subsidiarity and clinical engagement determine that change should be led as close to the front-line as possible without sacrificing alignment of the different aspects of change. This has led, for example, to the NHS Management Board asking itself quite explicitly what are the initiatives that we – and�only�we – can lead.

2. Ensure coherence. Ensuring that there is alignment and ample opportunity for co-production means using an easily understood

structure for organising and communicating your change process. Getting everything and everyone aligned and pointing in the desired direction is key for purposeful change. See the appendix for more on this.

3. Manage the change energy. Sequence your initiatives so that they generate sustained energy for change, and so that they maintain a sense of momentum. Keeping the different stakeholder groups energised is vital for success, particularly as the principles of co-production and clinical engagement will require high levels of energy from large numbers of people within the organisation.

One tool used for this is the three waves. The implementation of a comprehensive cultural change programme can take years. Therefore, implementation should take place in waves. In order to manage the change energy, sequence initiatives based on their potential for generating and sustaining energy. Prioritise initiatives around impact and ease of implementation.

frame 4

Tips & tricks

• Transformational energy needs to be built and managed continuously to fuel the change! In order to build it, focus on the convincing and inspiring delivery of a compelling change story

• When it comes to communication and engagement: more is more! Execute a number of different communication and engagement tactics to build momentum and energy for change

Premier mature operator in the

region

Regaining stakeholder confidence

▪ Deliver short term cost reduction promises

▪ Stabilise the production decline

▪ Outline a credible programme forward

Building towards world class

▪ Develop true ‘front-line’excellence– Rebuilding operations

capability– Develop world class

reservoir management

– Superior project delivery

Setting up for sustainable future

▪ Fix critical delivery processes

▪ Put lean and properly resourced organisation in place

▪ Rebuild the hydrocarbon maturation funnel

▪ Drive down longer term cost levels

Years 1 to 2 Years 2 to 3 Years 4 to 5

Declining performance and market

Figure 6 - Recent example of Change Architecture ‘waves’ used by an international oil company


The Benefits Hierarchy(The ‘Pyramid’)

It is important to measure changes to organisational and system health as well as the usual measures of performance and project implementation.

Organisations are deeply complex systems, with many hidden and often contradictory aspects. Initiatives which aim to influence them can have unintended and unpredictable consequences. As such, it is important to watch the progress of a cultural change effort as closely as possible, and at different ‘levels’ – the basic project outcomes, the actual changes in behaviour, performance outcomes and overall vision.

By default, most organisations going through a change process will measure the progress of implementation (e.g. milestones and budget). They will also usually measure their performance (e.g. clinical outcomes), and in the case of the NHS will also measure higher level outcomes such as population health outcomes. These measures are influenced by so many factors that it can be difficult to assess the contribution of the change initiative to those outcomes.

The Benefits Hierarchy reminds us that there are some layers between these two extremes – measuring organisation and system health, and its impact on performance (see figure below). What this means in practice is:

It is important during the change process to measure organisational and system health, and to make sure that the desired changes are happening. This may mean in practice regularly repeating some of the diagnostic tools such as surveys or interviews. Understand the linkages between organisational and system health and performance. As, for example, collaboration improves in an organisation it is important to understand whether the change is leading to a genuine improvement in performance, how and by how much. Assumptions will have been made during the diagnostic and design phases, and these need to be empirically tested to ensure that the change initiative remains on track.

1.

2.

frame 5

Programme metrics (e.g., initiatives delivered on time and to budget)

Organisational and system health

Public health

outcomes

Performance (e.g., specific aspects of

patient care)

• Implementation programmes are commonly measured, as are performance outcomes

• What can be missed is organisational and system health metrics

• These will provide valuable feedback on what is and is not working in your change programme

Figure 7 - The Benefits Hierarchy – Measuring Outcomes at Multiple Levels


Appendix

This appendix provides additional detail on the Five Frames. It is not intended to be complete or exhaustive, but rather to offer real-life examples of how the frames have been used, some of the empirical evidence underpinning them and more detail on tips and tricks for their use.


Performance & Health(The ‘And’)

frame 1

Appendix Frame 1

tools

Diagnosing Health with the Organisational Health Index (OHI)There are of course many ways to think about organisational health, as well as a number of tools available to help with the diagnosis. McKinsey & Co. has developed a model which considers nine dimensions of health (see figure below). This framework is supported by McKinsey & Co.’s Organisational Health Index (OHI), a survey-based diagnostic tool. These nine dimensions group to form three core themes: Alignment, Execution and Renewal.Health in the various dimensions is correlated with different aspects of performance. The OHI survey provides scores across the nine dimensions by examining thirty-four working practices. An example with a PCT is provided below.The nine dimensions are described below, as questions beginning with ‘How effective, and in what ways does the organisation...’:

Direction: …articulate where the organisation is heading, how to get there, and align people around the vision?Coordination & Control: …measure and evaluate performance and risk?Innovation: …generate flow of ideas and change so that the organisation can sustain itself, survive, and/or grow over time?Motivation: …inspire and encourage employees to perform and to stay with the organisation?Environment & Values: …shape the quality of employee interactions (e.g., culture, workspace design) and foster a shared understanding of core values?Capabilities: …ensure that the requisite internal skills and talent exist to support the strategy and create competitive advantage?External Orientation: …engage in constant two-way interactions with patients, suppliers, partners, or other external groups to drive value?Accountability: …design structure/reporting relationships and evaluate individual performance to ensure that people are accountable and take responsibility for performance?Leadership: …ensure that leaders shape and inspire the actions of other organisational members to drive better performance?

•

••

•

•

•

•

•

•

Figure 8 - Nine dimensions, three themes

Alignment

Are people at all levels aligned around the organisation’s vision, strategy, culture, and values?

Execution

How does the organisation execute in accordance with its strategy? Can the organisation perform essential tasks with its current capabilitiesand motivation level?

Renewal

How does the organisation understand, interact, respond, and adapt toits situation and external environment?

Cluster

Direction

Coordination and control

Accountability

External orientation

Innovation

Capability Motivation

Environment and values

Leadership

Elements of organisational health


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Application of OHI diagnostic in an NHS PCTAs part of its overall organisational development plans, a PCT conducted a deep organisational diagnostic using McKinsey & Co.’s Organisational Health Index. The OHI was one tool the PCT used as part of a rigorous process to: i) Understand the competencies and governance it required to fulfil the defined strategic priorities; ii) Analyse its current capabilities and capacities; iii) Determine the priority areas and potential solutions for its World Class Commissioning Development Plan. The OHI tool helped to identify a range of strengths and gaps in the organisational health of the PCT relevant to its goals. An implementation plan has now been developed to build on the strengths and address the gaps identified to achieve each World Class Commissioning Development Plan objective.

55

59

56

52

29

2030 2

11 8 21 29 2

32

1125

12 10 26

7

8012

18 6

30

1120 8

3422

16 14 12

▪People in NHS ABC feel personally accountable for the results they are expected to deliver

▪Leaders in NHS ABC consult with employees on issues that affect them

▪Good performance is recognised and rewarded in NHS ABC

▪Poor performance is identified and acted upon in NHS ABC

▪Employees in NHS ABC feel trusted to do their jobs well

67%

▪The responsibilities of my team/group are clear to me and to others across NHS ABC

67%

62%

59%

31%

22%

Strongly agree DisagreeAgree Strongly disagree

NeutralNot observed

Distribution of answers, %Survey questions% agree or strongly agree

Figure 10 - Survey details for one element of organisational health – Accountability

Average score ABC PCT

Distinctive

Superior

Common

Not effective

Maximum PCT score

Average PCT score

Direction

Leadership

Environment & Values

Coordination & Control

Accountability

Capabilities

Motivation

External Orientation

Innovation

% of respondents agreeing or strongly agreeing

NHS ABC’s capabilities are perceived as significantly below average

NHS ABC’s leadership is perceived as above average

NHS ABC’s accountability is perceived as below average

0 10 20 30 40 50 60 70 80 90 100

Figure 9 - Overall, the application of the Organisational Health Index tool shows a PCT which is in relatively good health

Based on the results of the OHI, the PCT has focused on three specific improvement areas:Developing robust talent and performance management systems to identify and reward good performance and provide developmental support where required.Building capabilities, particularly where these are necessary to deliver against the strategic plan and objectives.Developing systems to build accountability, e.g. cross-directorate working teams.

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•

•


The link between Performance and HealthThe insight behind this frame is that improving organisation and system health is as important as performance. Too often, short-term performance is prioritised over long-term goals. But ignoring organisational and system health typically damages future performance and makes it difficult to adapt to new directions (e.g. HQCfA) or environments (e.g. economic downturns).There is strong evidence for organisational health. The NHS Institute and Matrix Insight will publish a review in June 2009, titled “Organisational health: a new perspective on performance improvement?”, and to be available for download at www.institute.nhs.uk.Many high-performing companies struggle to maintain their success over time – a study of fifty-four high-performing companies showed that only 33% sustained performance twenty years after the initial research took place (see figure). Warnings of deteriorating health typically surfaced five to seven years before performance suffered. In health care, Ham et al (2003) showed that in pilot projects for the National Booked Admissions programme, only one-third continued changes after the 18-month pilot, and one-third failed to sustain their improvements.

R2 = 0.54

-2.0

-1.8

-1.6

-1.4

-1.2

-1.0

-0.8

-0.6

-0.4

-0.2

0

Strength of OHI

Unit 2

Unit 1

Distance index (gap to industry best performance benchmark)$ per unit produced

Small

StrongWeak

LargeUnit 3

Unit 8

Unit 4Unit 5

Unit 11

Unit 12

Unit 13

Unit 15

Unit 9

Unit 10 Unit 16

Unit 7

Unit 14

Unit 6

Gap to potential

Figure 12 - Organisational health has been linked to performance on a business unit level

Where are they now? (2002)

High-performers

Struggling

21%

46%

33%

Do not exist

Struggling

Still highperformers

43

18

54 companies‘built to last‘ *

(1982)

(1997) * 7 companies are common to both

Figure 11 - High-performing companies struggle to maintain their success over timeevid

ence

Performance and health have been quantitatively linked. Companies with top scores on key health indicators are twice as likely to have above median financial performance compared to unhealthy companies (see figure on page 11). The relationship between performance and health also exists at the business unit level (see figure below).


"If we dissect what we do right and apply the

lessons to what we do wrong, we can solve our

problems and energise the organisation at the

same time. What is more useful – to demoralise a

successful workforce by concentrating on their

failures or help them over their last few hurdles by

building a bridge with their successes? Don't get

me wrong, I am not advocating mindless happy

talk. We cannot ignore problems, but we just

need to approach them from the other side"

– T. H. White, President GTE Telephone Operations

"When we were most successful, what were we doing?"

"What does it look like when we areat our best?"

"What possibilities exist that we have not yet considered?"

"What is the smallest change that could make the biggest impact?"

"I will be most proud of this corporation in 2010 when..."

Example questions

Figure 13 - Asking questions around the positive attributes of an organisation will recognise strengths and enhance value

tips

& t

rick

s In McKinsey & Co.’s framework and the related OHI tool, organisational health is driven by the nine organisational dimensions, explained above, and thirty-four underlying management practices. In creating the aspiration focus on improving a limited set of practices crucial to your specific system. Identifying and targeting these will deliver better results than spreading your effort across the whole broad set.Small, gradual changes are less easy to make and sustain than big ones! Radical, sweeping changes are often more successful, because they quickly show results. Create an aspiration around performance and health which is ambitious, bold, and inspiring. The aspiration should articulate a sustainable step-change in performance and health and be anchored in the reality of today.You always get more of what you ask for! Focusing on what doesn’t work is much less powerful than focusing on what already works well. In workshops use the method of Appreciative Inquiry to identify what works well and leverage pockets of strength in the change strategy (see figure for example questions).

•

•

•

Employees will commit most to what they have understood, done and decided themselves! Much of the energy invested in explaining the need for change would be better spent on direct upfront involvement. Use the output of the fact-gathering to hold up the ‘mirror’ in a workshop and involve as many key stakeholders as possible in confronting the reality of today. Build ownership by letting them discover the need for change themselves.The organisation may not be homogeneous! ‘Identity group’ cultures (i.e. groups within an organisation) have a more immediate effect on individual employee behaviour, while organisational culture is key to aligning across groups. The two must therefore co-exist and be shaped as mutually reinforcing. During the fact-gathering phase, understand the balance between the groups’ cultures and the organisation’s culture, and whether the organisational culture is strong enough to allow sufficient coherence. Involve stakeholders from the most relevant groups early to gain ownership. Think about system health as well as organisational health! The NHS is not a single organisation, rather it is a system of organisations which interact. One implication of this is that leaders of organisations also have a role as leaders within the system, and so thinking about system health as well as organisational health is important.We are in the health business – for healthy organisations as well as people! It is a powerful construct to apply the ‘health’ metaphor to our organisations and systems as well as the populations and patients we serve. To achieve our goals, we need the NHS system to be healthy – and the other groups and systems that it interacts with to be healthy as well. We cannot ignore parts of the system. In a healthy system, leadership styles must be based upon influence more than control.

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The Discovery Process of the Management BoardThe NHS Management Board went through a facilitated Discovery Process, to identify desired shifts in their own behaviours and mindsets. Below is a subset of the mindset from-to’s which they agreed. This set provided the input to the Influence Model frame, as initiatives were devised to support these shifts.

Appendix Frame 2

Value and quality

We care about quality butour focus is on resources and narrow quality metrics

We focus on cost, quality and value for moneyanddo not think about one without the other, because every pound wasted is someone’s lost opportunity

Working together

We are proud of how we execute and what we achieveandrecognise that we need to work in and learn from partnerships within and outside the NHS to achieve more, for us, my team and the whole system

We have individual accountability and consequencesbutdo not collaborate well within my organisation and beyond

To . . .From . . .

We want to excel professionallyandfeel ownership for achieving world-class outcomes and standards for the system

We have minimum standardsbutmediocrity is good enoughExcellence

We have a focus on deliverybutonly targets and fear make people deliver

Challenge & Support

We want to feel challenged and challenge others andbe supported and support others in striving for ever better outcomes

Innovation

We will be recognised for success andwant to learn from failure as well as success in our restless pursuit of change and improvement through innovation

We want to improvebutinnovation is risky and failure will be punished

1

2

3

4

5

…

Figure 14 - Excerpt of outcomes of the Discovery Process – NHS Management Board example

The Discovery Process(The ‘Horseshoe’)

frame 2

Outcomes

Practices

Mindsets

Outcomes

Practices

Mindsets

Current DesiredExamples Examples

� System biased towards cure as opposed to prevention

� Marginal expenditure and investment is not always spent most effectively

� Some conditions (e.g., dementia) receive disproportionally little attention and few resources

� Budget allocation used to drive capacity building and cost cutting, not clinical excellence

� Mental health is not considered as important as physical health in prevention, diagnosis and treatment

� Workforce not sufficiently reviewed for effectiveness

� More people are granted better and faster access to the system

� All patients have access to the best available treatment and care

� Care is provided in the most efficient and convenient way to all patients

� Funding is used to encourage clinical excellence

� Greater focus on prevention� Resource allocation must be based on

disease factors, clinical factors and patient factors like experience and access

� Quality and efficiency are closely interlinked

Breakout groups populate the lower bend of their Discovery Process with ‘current’ and ‘desired’ mindsets

Pre-populated outcomes and practices can be amended and added toworkshop materials

Figure 15 - Sample output of a Discovery Process workshop with the NHS

The desired and current outcomes, behaviours and mindsets were populated in a fact-gathering phase, drawing on HQCfA, interviews and workshops. Below is an example of how the ‘Horseshoe’ is followed during a workshop.


There are of course many diagnostic tools available that can be used as inputs to the Discovery Process. One of these is McKinsey & Co.’s Culture Survey. This can be used to highlight the key characteristics of a working culture which the team sees today and would like to see in the future. The tool is described in more detail later on in the appendix. The figure below gives an example output of the values survey used in one area of the NHS.

Top 10 current

Reactive

Accountability

Internal politics

Results-oriented

Task-oriented

Silos

Having a noble purpose

Operational focus

Acknowledge Keep Build

Top 10 desired

Values-driven

Making a difference

Being adaptable

Continuous Improvement

Courage to do what’s right

Quality focus

Excellence

Customer focus

Inspirational

CaringSlow-moving

Bureaucracy

Inconsistent

Hierarchical

Figure 16 - Sample output of Culture Survey used in the NHS


“We think, we already know everything . . . there is nothing to be gained from looking outside”

“It is not worth my job to challenge the status quo”

“Mistakes are hidden and not used as an opportunity to learn”

“If it’s not broke, don’t fix it”

“Innovation is risky”

▪ Lack of motivation: Employees perceive there are no rewards for pushing the boundaries

▪ Arrogance: Leaders and employees believe that they are the best

▪ Lack of respect: Leaders do not believe that employees have anything to contribute

▪ Fear: Employees fear the consequences of challenging their leaders

▪ Blame: Employees believe people are quick to blame if a new idea goes wrong

Typical underlying mindsetsExample symptoms

Figure 17 - Stifling innovation - Example symptoms and typical underlying mindsets from banking industry

Typical mindset changes that enhance innovationAcross organisations, evidence shows that there are a number of typical mindsets that stifle innovation and entrepreneurship. Identifying and shifting those beliefs is key to enhancing innovative organisational capabilities – without changing them, process redesign is less successful. The examples given below show how the process worked for an organisation in the banking industry. The first figure shows how some symptoms are linked to a set of underlying mindsets. It is these mindsets which ultimately need to be addressed. The second figure shows the shifts in mindsets which the team identified as desirable.

“Probing my client about its financial situation is prying into its private affairs”

FROM: Transactional TO: Relational

“I am responsible for addressing their articulated and unarticulated needs”“Understanding my clients’ full situation is the only way I can appropriately advise them”

“My success depends on optimising my area”“I view other areas as a hindrance –‘they’ are incompetent and selfish”

FROM: Silos TO: Collaboration“My success depends on helping optimise the company result”“There is no ‘they’ – I assume competence and goodwill in other areas”

“The problems we face are beyond my control““I show up at every meeting so I can watch my back”

FROM: Blame TO: Accountability

“If I’m not part of the solution, I’m part of the problem”“I trust others to do what they are supposed to do in a fair manner”

Figure 18 - Typical examples of mindset shifts necessary to enhance innovation from banking industry

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Impact of mindset and behaviour transformationsIdentifying crucial mindset shifts is one vital step in the journey towards increasing health. Transforming those mindsets and, with them, the behaviours that drive performance comes next. A wide range of successful programmes give evidence that underlying beliefs can be effectively changed over time. The exhibit below shows an example of a bank which wanted to make quality its core focus.

1Cost reduction

Quality focus

Cost reduction Cost reduction Cost reduction Quality focus11 1 1

Shareholder value Profit Shareholdervalue

Quality focus Cost reduction 2 2 2 2 2

Results orientation

Shareholder value Accountability Shareholder value Accountability 3 3 3 3 3

Profit Results orientation

Quality focus Accountability Continuous improvement

4 4 4 4 4

Goals orientation Profit Continuous improvement

Achievement 5 5 5 5 5

Bureaucracy Continuous improvement

Results orientation Profit Profit 6 6 6 6 6

Hierarchical Quality focus Continuous improvement

Results orientation Results orientation 7 7 7 7 7

Short-term focus Bureaucracy Achievement Achievement Community involvement

8 8 8 8 8

Control Achievement Bureaucracy Community involvement

Shareholder value 9 9 9 9 9

Risk averse Goals orientation Being the best Customer satisfaction

Customer satisfaction

10 10 10 10 10

28

Accountability

Year 0 Year 1 Year 2 Year 3 Year 4

Figure 19 - Example – In annual surveys about their company’s values, employees of a major bank ranked quality higher each year

evid

ence

“ I will change my approach to work and to the benefit of the company. Don’t let it fade out”

“ Best personal development programme I’ve been on. A powerful change agent programme for the company – from culture will flow value”

“ An enlightening experience with a profound impact on the way I see myself and the way others see me. With the commitment which I already sense, the workshop will create a visible shift in the company’s culture and values”

“ A very good programme. It has the potential to truly help transform the company, and we’re clearly seeing the impact already”

Example quotes from a mindset and behaviour transformation


tools

What a Discovery Process workshop can look likeA Discovery Process workshop uses input from the fact-gathering phase to start and focus the discussion. Surveys and/or interviews are valuable sources of insight into the current ‘reality’ of the organisation or system. One tool that can help with the diagnostic is McKinsey & Co.’s Culture Survey. It allows you to identify the key characteristics of the current culture which the team see today, and those they aspire to for the future. The team can then examine the extent to which they overlap. In an internet or paper survey on perceptions of the company’s culture, participants pick 5-10 words from a list that most or least describe their personal values, as well as their current and desired organisational experience. An example output can be found earlier in this section.During the workshop, work in breakout groups around specific categories of practices or outcomes, then discuss findings (see figure for an example agenda of a Discovery Process workshop).

Time Topic Description

09.45-10.10 Introduction to the Day ▪ Introduction to the day

10.25-11.15 The Discovery Process breakouts(Breakouts – facilitated)

▪ 4 mixed groups of staff from different levels▪ Each breakout around a single topic, e.g., clinical procedures,

capabilities, resources, innovation ▪ Examples of outcomes and practices provided for each topic▪ Single example of a mindset (from – to) provided for each topic▪ Outputs– Edited poster with outcomes and practices – Poster with current and desired mindsets on post-it notes

11.15-11.30 Feedback ▪ Short presentation by each breakout group of the current and desired mindsets

10.10-10.25 The Discovery Process ▪ Introduction to the detail of the Discovery Process, including a simple example of the process

11.40-11.55 Prioritisation session(Presentation and Gallery walk)

▪ Introduction to mindset grouping by facilitator▪ Each participant is then given stickers to stick onto the mindset

groups that provide the greatest opportunities for raising quality in the system

12.25-12.30 Wrap up and next steps ▪ Thanks for useful input▪ Outline of next steps

11.55-12.25 Feedback ▪ Summary and synthesis by facilitator of which mindset groups provide the greatest opportunity for raising quality

▪ Pair-share discussion on initiatives that could facilitate these mindset changes

10 minute tea break

Figure 20 - Example agenda for a Discovery Process workshop


tips

& t

rick

s Probing for the root causes of behaviour is difficult and can be uncomfortable! Use an experienced, impartial facilitator for the workshops. The most powerful change themes often have their origin in a dilemma! They are about shifting from the belief that you can either do one thing or the other to believing in being able to do both at the same time (e.g. reducing cost and increasing patient satisfaction). In probing the root causes of behaviour pay special attention to potential dilemmas. Question existing beliefs on relationships between behaviours and mindsets.Identify mixed blessings! Some common practices typical for your system might simultaneously have good and bad effects on your strategic objectives. For example, healthy competition can be a useful impetus, but taken too far it can hamper collaboration. Identify those ambivalent practices and drill down to the mindsets driving them. On the mindset level there will often be a possibility to reap more of the benefit while avoiding the downside.

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Maternity service in an NHS hospitalA maternity service in an NHS hospital was found to under-perform compared with other maternity services in different organisations, as well as to other services within the trust. The Influence Model was used to devise a balanced set of actions that addressed this. The highest potential actions were then piloted, followed by roll-out of those that worked. One year later, performance measures have improved significantly (e.g. satisfaction of the women who use the service has gone up by more than 50%). Below are the actions around the Influence Model, together with detail on some of the successful actions.During the idea generation phase the Influence Model was used to determine a balanced set of co-ordinated interventions, covering all four elements required to embed change (see figures).

�� | Building a Healthy NHS: Introducing the Five Frames

Appendix Frame 3

Agreed standards of behaviourfor all

Increased senior doctors’Presence on labour ward

• Created a list of standards, based on ‘Putting Patients First’ guidelines

• These show the behaviours that everyonewill display (no matter how senior)

• Senior doctors located in clinical areas, or in adjacent on call office when on-service

• Senior doctor personally leads rounds and daily quality meeting

Daily quality meetingImproved doctor/midwife communication

• Introduce a daily, multi-disciplinary quality meeting at shift handover

• Six item satisfaction questionnaire used with all mothers

• Scores displayed and discussed at daily quality meeting

Whiteboard show-ing survey results

• Were you treated with• kindness and respect?• Was the information provided• during labour appropriate to

your needs?• Did staff respect your privacy • and dignity? • …

Six questions

Figure 22 - Examples of some key interventions in an NHS maternity service

Interventions

Fostering understanding and conviction“I understand why continuous learning is important for our organisation and what my role is in it”

Role modelling“I see superiors, peers and subordinates behaving ina way that encourages learning”

Developing talent and skills“I am supported in continuously developing the skills and capabilities I need"

Reinforcing with formal mechanisms“The structures, processes, and systems reinforce continuous learning”

Widely engaged staff about what ‘great’ wouldlook likeAgreed a shared vision of what the service should look like Based on this vision, created a performance scorecard

Created standards of behaviour for allIncreased presence of senior clinicians in clinical areasIntroduced joint ward rounds for midwives and doctors

Trained staff on: Interpersonal styles and team effectivenessRunning workshopsGiving and receiving feedback Building the change story

Instituted daily quality meeting, led by senior doctorsUsed visual management board to present data, updated dailyClarified midwifery management structure to ensure clear role definition and reporting linesReduced time spent by clinical staff on non-clinical activities

Figure 21 - Interventions were designed on four levers reflected in the Influence Model

“ I feel like I’m working in a new hospital!”

– Midwife

“ Vastly improved from when I had my son here two years ago”

– Mother

“ For the first time I understand what the world looks like through a mother’s eyes – and a midwife’s”

– Senior Doctor

The Influence Model(The ‘Jigsaw’)

frame 3


Building organisational health in banking using the Influence ModelA major Australian bank, ANZ, has undertaken a comprehensive change programme targeted at building organisational health that has led to a step change in terms of performance.A fact base and a common vocabulary were established up-front using culture surveys, deep structure interviews and focus groups. The root causes of current business challenges were determined and a set of a few critical mindset shifts was agreed on.Actions were defined around the Influence Model to create a balanced set of changes to the employee environment, which promoted new behaviours. The figure below shows the set of actions agreed for each influence category.

“ Three and a half years ago, ANZ Bank was the worst performer of the big four banks... the transformation has turned ANZ Bank from a lame duck into a highly polished, money-making machine.”

— Business Editor,Australian Financial Review

•Created a transforming top team always one step ahead of the broad effort (via coaching, 360s, facilitation, team charter)

• Invested heavily in the top 100-300 leaders as role models

• Identified and cultivated ‘change champions’ from all levels in both formal and informal leadership roles

Role-modelling

•Adjusted formal skill-building programmes to incorporate culture overlay and build needed skills (e.g. relational sales, giving feedback with compassion)

•Adjusted on-the-job development activities to include desired shifts (e.g. development plans, self-guided learning)

•Adjusted hiring and promotion practices to reflect desired culture

•Created a meaning-laden integrated change story (setting cultural aims in the context of the broad transformation)

•Cascaded the story into the organisation in a personally meaningful way (writing their own stump speeches)

•Complemented existing communications efforts with ‘break the mold’ approaches such as ‘viral’ communications

•Hardwired desired mindset and behaviours into performance management, moving to more balanced scorecard approach linked to compensation

•Published quarterly performance for every business unit publicly both internally and externally

• Instigated ‘silly rule button’ to cut through poor processes

Fostering understanding and conviction

Developing talent and skills Reinforcing with formal mechanisms

Figure 23 - Overview of initiatives addressing culture change

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4 1

23

Leadership actionsOpinion shapersInteractions

Story development (includes all the key elements, e.g., values, strategy, case for change)Story delivery (across relevant levels, i.e., organisational, employee, functional)

Organisation structureTargets and metricsManagement processesBusiness processesRewards, recognition and consequencesInformation systems

Talent managementHiringReplacingRetaining

LearningOn-the-job developmentTrainingAction learning

Lever categoriesLever categories

Role-modelling

Fostering understanding and conviction

Developing talentand skills

Reinforcing with formal mechanisms

“…I see leaders, peers and reports behaving in the new way“

“…I know what is expected of me, I agree with it, and it is meaningful“

“…I have the skills, capabilities and opportunities to behave in the new way”

“…The structures, processes and systems reinforce the change in behaviour I am being asked to make“

Figure 24 - The Influence Model and lever categories

tools

Defining a balanced set of initiatives In order to create a well-balanced change strategy, brainstorm initiatives across all four categories of the Influence Model, and make sure you don’t have a ‘blind spot’ or an overused quadrant. The figures below are meant to provide some thought starters on the types of actions for each category, including more detail on the ‘Role Modelling’ category.

InteractionsInteractions

� Improve quality of direction, interaction and renewal

– Identify and agree on team roles and priorities

– Spend time analysing the root causes of problems

– Provide coaching to individual members

� Understand current degree of alignment around corporate story/change agenda

� Increase visibility of leaders through regular staff interaction

� Create forums for leaders to interact with the rest of the organisation

� Use symbolic language and actions to emphasise importance of the desired change to patients and staff

� Identify influential stakeholders from all levels of the organisation

� Understand reasons for resistance

� Change team composition to include key opinion leaders in change processes

� Ensure top management ownership of change through linkage of programme success to their evaluation and rewards

� Task change agents to carry the message to their environs

Description

� Enlisting the support and involvement of influential stakeholders at all levels of the organisation to assist in shaping the desired behaviors

Opinion shapersOpinion shapers

� Ensuring that group dynamics are effective in pivotal performance groups

� Setting an example of exemplary behaviour in day-to-day interactions with subordinates and patients

Leadership actionsLeadership actions

Example actions

Figure 25 - Example actions – Role modelling


Testing for ‘Goodness of fit’

Leadership

External orientation

Direction

Accountability

Environment and values

Capability

Innovation

Influence Model initiatives

Profile elements

Coordination and control

Motivation

XX

X X

X

X

X

X

X

XX

X X

X

X

X

X

X

XX

X X

X

X

X

X

X

XX

X X

X

X

X

X

X

1. Consistency: Ensure alignment of actions among performance model elements

2. Complementarity: Ensure integrated actions are taken across all 4 influence model quadrants

3. Comprehensiveness: Ensure sufficient actions are taken across performance profile and influence model to achieve desired outcome but taking care not to overwhelm the organisation with too many actions

4. Context: Ensure actions are aligned with the organisation'sstrategic objectives and context

‘Goodness of Fit’ is the extent to which thecomplete set of initiatives are consistent, complementary, comprehensive, and context-specific

Figure 26 - Testing for ‘Goodness of fit’

When you prioritise the initiatives and design the change architecture, revisit the Influence Model to test the overall ‘goodness of fit’ of the change process. The set of initiatives should ideally be consistent, complementary, comprehensive, and context-specific.


Description

Acquired knowledge, skills, and capabilities that enable individuals to act in new ways

Human capital

Social capital

Knowledge, skills, and resources available in and through the personal and professional networks of employees

Business impact on . . .

Innovation Employee turnover

“We made lots of effort to train the commercial bankers, then as soon as we promoted them, our competitors would offer them a role”– HR director,

financial services, Europe

“We trained someone andthen lost him to a hedge fund in New York”– Senior manager,

financial services, NA

(0.47)* (-0.41)*

(0.20)* (0.29)*

Illustrative interview quotes

* Denotes a statistically significant relationship

Figure 27 - Investing in human capital alone, without a dual focus on creating social capital, can actually increase employee turnover

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s Fear or stress can only motivate temporary change! For change to be sustainable, leaders must engage the organisation with a vivid, meaningful and exciting vision of the future! To foster understanding and conviction, engage staff with a meaningful story that combines positive, supporting messages with hard facts that stress the need for action.Working on just one corner of the Influence Model can be less effective or even counter-productive! For example, investment in human capital without also developing a supportive infrastructure increases employee turnover, as it builds confidence and skills without enhancing employee commitment. Therefore, investing in talent and skills – one category of the Influence Model – is not enough. In addition to building individual capabilities, also invest in social capital in order to strengthen the bonds between employees – the glue that holds the organisation together (see figure). One survey of 50,000 employees, at 59 organisations worldwide, found that people with lower social engagement were four times more likely to leave their jobs. Plus, each time we avoid a member of staff leaving, we save £15,000 in new staff orientation and lower productivity, as well as the effect on morale for remaining staff.

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56% of transformations that set good targets succeeded, while 88% of those who set badly defined targets failed

% of respondentsTotal respondents = 2,694

The targets were well defined in financial or operational terms and represented a genuine new level of performance

The targets were well defined in financial or operational terms but did not stretch the company significantly

The targets were not well defined

Which of the following statements best describes the targets your company set to define success for the transformation?

1046422

324694

27414 10

Extremely successfulVery successfulSomewhat successfulNot successful at all

Degree of transformation success

Figure 28 - Invest in setting clear, stretch targets – nine out of ten transformations with ill-defined targets fail

Money is the most expensive way to motivate people! Non-financial incentives can be not only cheaper but also more powerful than money. In some cases expected financial incentives can even undermine intrinsic motivation. Whenever possible use social rewards (compliments and praise) and positive feedback to enhance motivation. From time to time employ small, unexpected rewards to show appreciation and boost change motivation.Employees need to be connected with a sense of purpose to motivate their full effort and engagement. Such a sense of purpose is most powerful when it is rooted in the organisation’s heritage as well as clearly consistent with its strategy. To engage employees, ensure that the story is driven by a clear and persuasive rationale that takes into account the organisation’s heritage and strategy as well as their individual motivations. Also, understand why certain strategic directions are more or less available dependent upon legacy and proceed from there.Well-defined stretch targets are key to a programme’s success! Setting challenging and specific goals with the opportunity for feedback greatly improves employee performance. Reinforce with formal mechanisms: invest up-front in definition of targets in clear financial or operational terms that represent a genuine new level of performance (see figure).Build some ‘quick wins’ into your change process! Quick wins build momentum and energy as the perception of success is created and stakeholders get engaged. They can also provide ‘air cover’ by demonstrating results while you plan more complex aspects of the change process.

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tools

Creating the Change ArchitectureIn order to ensure that the change initiative is well understood, the transformation leader – typically the CEO – and the core team need to design a three-level structure that links initiatives and themes to the change story, and to assign accountability for elements on all levels.

Appendix Frame 4

Estimated costs/impact Buy-in/ownership Recommendation

Potential staff resistance

Role modeling� [E.g. Champions]

Formal mechanisms� [E.g., Process changes]

CostX GPB/quarter

Wave 1

Impact[E.g., increase quality]

Initiative factsheet: [Initiative name]

[What does success look like]

Risk

High

Medium

Low

Risk

High

Medium

Low

Ownership

� Initiative Leader: xxx

Initiative team ownership

Initiative and aspirations Outputs/coverage of organisation

Measures and targets

Understanding� [E.g. Workshops]

Skills and talent� [E.g, Non-mg skills]

[E.g., Patient satisfaction

From To

X% (2008) Y% (2009)]

� [E.g, potential staff resistance]

Figure 30 - Factsheet for planning change initiatives

L2: Change themes

L1: Overall change story

L3: Initiatives

Figure 29 - The use of a three-level structure grouping the initiatives into change themes and linking them to the story helps ensure coherence

Change Architecture(The ‘Waves’)

frame 4

Owners of initiatives should then scope and plan their respective initiatives. (An example is below.) Doing so in a decentralised fashion will build buy-in throughout the organisation. However, those plans must be relayed back to the senior leadership so that initiatives can be prioritised and sequenced. A programme management office or change team is an important consideration at this point to support initiative owners with tools and guidance for their tasks, to collect results, and to manage the overall sequencing.


Application of three-level structure in performance transformation The three-level structure linking the individual initiatives through change themes to the overall change story is a standard tool taken from performance transformation work. The example given here is taken from the transformational journey of a basic materials manufacturer aiming for a step change in terms of customer focus and operational excellence. Vision, core themes and initiatives in this example reflect the three levels (L1-L3) of a coherent transformation programme (see figure). In this case, the initiatives have first been piloted in two business units and subsequently rolled out in waves across the organisation.

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Eight Initiatives (L3)

• “By 2010, we will become the reference X maker. We will capture present and future client needs better than any competitor.”

• “We will operate optimally to fulfill these needs, and develop an incomparable pool of talent to make this happen.”

One Vision (L1) Three Core Themes (L2)

Building a unique talent development platform

Developing aleading production system

Fostering commercial excellence

Develop the long-term commercial strategyAlign mindsets and capabilities, processes, systems to execute

Determine long-term optimal industrial configurationIncrease the reliability of production facilitiesAccelerate the cost reduction Determine the optimal way of organisingsupport services

Develop an integrated performance management systemDevelop an attractive and coherent people development and performance rewarding system

Figure 31 - Example – Performance transformation of a basic materials manufacturer: one aspiration, three core themes and eight initiatives


0

1

2

3

4

5

6

Extremely

Average number of tactics used to mobilise staff

Extent to which transformation was successful

% of respondentsTotal respondents = 2,694

VerySomewhatNot at all

Using tactics to mobilise staff

Companies that used more mobilising tactics, such as creating a compelling change story, were more likely to be successful

Figure 31 - Investing in a set of different tactics to mobilise staff pays off

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s Transformational energy needs to be built and managed continuously to fuel the change! In order to build it, focus on the convincing and inspiring delivery of a compelling change story and on the behaviour of the leaders.When it comes to communication and engagement, more is more! Organisations that use more mobilising tactics are more likely to be successful (see figure). Execute a number of different communication and engagement tactics to build momentum and energy for change.Frame the change in ways that connect with the values and life experiences of the workforce! Do not assume that one message will reach every group of stakeholders you need to get on board. The message to senior clinicians must be framed very differently than the message to leaders of the finance function.

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The amount of detail given on the individual frames reflects their level of development and exposure within the NHS. As the Benefits Hierarchy is still an evolving concept no additional detail is given on this frame.


next

steps So what can you do now?

Now that you have the context for the scale of change required across the NHS, we would like you to have a conversation with your team about the implications, opportunities and challenges for the part of the system you and your team lead.As part of this, your team might consider:

What types of changes to how people work might be required, both in your team and in your organisation and/or part of the system to deliver HQCfA;How ready your organisation is to deliver the required changes;How likely you are to succeed in achieving the required change, based on current activities or programmes.

If you think all or some of the Five Frames introduced here may be of use to your team, you can contact the NHS Institute for more information. (Email Annette Neath at [email protected].)

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Inspiring change in the NHS: the five frames

Healthcare

Transcript of Inspiring change in the NHS: the five frames