How to Be a Great Change Agent - Minicourse M10

IHI National Forum on Quality and Safety

Minicourse M10
How to Be a Great Change Agent
Monday 9th December
Crystal Ballroom, Salon D
8.30am to 4.00pm

Helen Bevan @HelenBevan
Robert Varnam @RobertVarnam
Andrew Hasler @AndrewHasler
#IHI25Forum #ChangeAgents
@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents

What it says in the brochure….
It’s tough being a change agent, particularly when other
people don’t want to change. Yet big change happens in
health care organizations only because of heretics:
passionate people who are willing to take responsibility
for change. Such individuals support organizational
goals, but also want to change existing thinking and
practice and improve care for patients. This session
provides a toolkit for surviving and thriving as a change
agent.
After this session, participants will be able to:
• Identify and practice tactics for being an effective
change agent
• Build a toolkit of powerful approaches to enable
change
• Connect with and learn from other change agents

Today we are part of a global community
of change agents
• We will monitor and synthesise tweets all day, including
those from fellow change agents who are connecting
virtually
• We will produce summaries of the minicourse:
• Storify
• Pinterest
• Please use both hashtags #IHI25Forum and
#ChangeAgents


What happens to
heretics/radicals/rebels/mavericks
in organisations?

@helenbevan

@helenbevan

“There is nothing more
difficult to carry out, nor
more doubtful of success,
nor more dangerous to
handle, than to initiate a
new order of things. For the
reformer has enemies in all
those who profit by the old
order, and only lukewarm
defenders in all those who
profit by the new”
Niccolo Machiavelli 15th century
@helenbevan

Task
We are going to talk to others on our table about our
experiences of being a change agent and challenging the
status quo
• Pick a picture card from the pack that reflects your
experience
• In turn each person at the table should take turns to:
• Introduce yourself to others
• talk about your experience (and why you picked the
picture)
Time allowed (for whole table): 15 minutes
@helenbevan

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
@helenbevan

Sometimes people see us radicals as
troublemakers

Source : Lois Kelly www.foghound.com
@helenbevan

Task
• Talk to others at your table about your
experiences around “radicals” and
“troublemakers”
• Which have you been and why?
• What moves people from being “radical” to
“troublemaker”?
• How do we protect against this?

@helenbevan

First they ignore you, then they laugh at you,
then they fight you, then you win
Gandhi

@helenbevan

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

@helenbevan

@helenbevan

Source: Foghound

Emerging themes in large scale change
Dominant
Organisation
approach
Power through hierarchy

Emerging
direction
Community
Power through connection

Mission and vision

Shared purpose

Making sense through
rational argument

Making sense through
emotional connection

Leadership-driven (top
down) innovation

Viral (grass-roots
driven) creativity

Tried and tested,
based on experience

“ Open” approaches , sharing
ideas & data, co-creating change

Transactions
@helenbevan

Relationships
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

and
@helenbevan

The Network Secrets of Great Change Agents
Julie 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

@helenbevan

Across the world, the change agent
movement is exploding!
@chagww
Changeagentsworldwide.com

@rebelsatwork rebelsatwork.com

@corprebels
Corporaterebelsunited.com

@helenbevan

Source: @NHSChangeDay

@helenbevan


www.changeday.nhs.uk/healthcare radicals

@helenbevan

Five tactics for change agents
1. Start with myself
2. Build alliances
3. Work out what might help others to
change
4. Create energy for change
5. Don't be a martyr

@helenbevan

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

Source: adapted from Debra E Meyerson

@helenbevan

 we surrender a part of ourselves, and silence
our commitment, in order to survive


@helenbevan

2. leave the organisation


@helenbevan

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


@helenbevan

3. stridently challenge the status quo in a manner
which is increasingly radical and self-defeating

@helenbevan

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
@helenbevan

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

@helenbevan

What do we know about successful boat rockers?
1. convictions and values-driven
2. strong sense of “self-efficacy”



belief that I am personally able to create change
belief in others

3. action orientated



ignite collective action
mobilising others, inspiring change

4. able to join forces with others


work as a collective body for commonly valued changes

5. able to achieve small wins which create a sense of hope, selfefficacy and confidence
6. optimistic in the face of challenge



see opportunities
take account of obstacles


@helenbevan

Three assumptions for change agents
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
@helenbevan

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

@helenbevan

Task
Talk to others at your table about moving
beyond skills and knowledge of improvement to
live and be improvement
• What are some of the ways that we already do
this?
• How could we do this more?
• What are the implications for the way we
work?
@helenbevan

2. Build alliances
3. Work out what
might help others to change

@helenbevan

The easiest way to thrive as an outlier
...is to avoid being one
Seth Goodin

@helenbevan

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

@helenbevan

@helenbevan #IQTGOLD

What’s the
financial incentive?
What’s the
project plan?

Who is
performance
managing?

@helenbevan

or

“I have some KPIs
for your”
“I have a dream”


Call to Action

@helenbevan

What do you
want to
achieve?

@helenbevan

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)

@helenbevan

A good narrative motivates others by:

• achieving common purpose through
shared values and commitment
• uniting us around a collective vision ,focusing
our energy towards a specific and real change
• creating contagious commitment

@helenbevan

Values
Emotion

Source: Marshall Ganz

But not all emotions are equal.........
urgency
anger
hope
solidarity
you can make a
difference

Action inhibitors

Overcomes

Action motivators


inertia
apathy
fear
isolation

Self-doubt

Developing your narrative
Individually:
• Using the narrative worksheet on pages 7 and
8 of your workbook please consider the
questions raised
• This prompt sheet will help you to capture key
points into one area without the need for
writing a script
@helenbevan

Public narrative
a skill to motivate others
to join you in action


Made in Dagenham

story of

self

story of

PURPOSE

call to leadership

now
strategy & action

story of

us

shared values &
experience



story of

self

story of

PURPOSE

call to leadership

Why I am
called to do
this work

now
strategy & action

story of

us

shared values &
experience



story of

self

story of

PURPOSE

call to leadership

now
strategy & action

story of

us

shared values &
experience


Our shared
experience
reveals our
shared values


Frame the urgency &
hopefulness necessary to secure
commitment & build momentum
towards our shared goal

story of

self

story of

PURPOSE

call to leadership

now
strategy & action

story of

us

shared values &
experience



Frame the urgency &

story of

self

story of

PURPOSE

call to leadership

Why I am
called to do
this work

now
strategy & action

story of

us

Our shared
experience
reveals our
shared values

shared values &
experience


Marshall Ganz

www.youtube.com/watch?v=LM-fxPrSZZ8


Storytelling elements
o shared experience – shared values
o emotion
o plot
o vivid detail
o key touch points

Creating a plot
• 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?
@helenbevan

Vivid details



The power of stories

What did it
achieve?

How does
this make
you feel?

How did it
achieve it?

@helenbevan

Frame the urgency &

story of

self
call to leadership

Why I am
called to do
this work

story of

PURPOSE

Your
turn

now
strategy & action

story of

us

shared values &
experience


Our shared
experience
reveals our
shared values


Working in trios
• Storyteller
• Listener
• Observer

@helenbevan

Storyteller
• Tells story of self
• Reflects taking notes, what did I do well what
might I do differently next time?
• Receives feedback from the listener and
observer

@helenbevan

Listener
• Reflects upon how the story makes them feel,
did it connect with them and why?
• What were the key touch points for you?
• Was there use of vivid detail or data?
• In listener role the story will build each time
you hear it, is there a plot, character,
challenges and choices
•
@helenbevan

Observer
• Manages the process, timing is important as
is ensuring that each group member has an
opportunity to give and receive feedback.
• Allows about 3-4 minutes for the story teller
to tell their story of self
• 1 minute for writing down reflections
• Allows about 3 minutes for feedback from the
group starting with the story teller, listener
and observer
• Change roles and repeat.
@helenbevan

Giving feedback
• Was the
– challenge
– choice
– Outcome

explicit?
• Could you identify with their values? Where did
they come from?
• Were the details vivid in ways that helped you
to identify what she/he was feeling?
@helenbevan

“If people give to a cause, they expect a
relationship, not a transaction”
Nilofer Merchant

@helenbevan

“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

@helenbevan

Case study:
people with dementia and
antipsychotic drugs

@helenbevan

“short-term treatment (up to six weeks) of
persistent aggression in patients with moderate
to severe Alzheimer’s dementia, unresponsive
to non-pharmacological approaches & when
there is a risk of harm to self or others”.
@helenbevan

The reality was
• Estimated 180,000 people
in England with dementia
were getting antipsychotics
• Only 36,000 get any clinical
benefit from the drugs
• Negatives far outweigh the
positives
Source: Bannerjee report

@helenbevan

It doesn’t have to be that way!

@helenbevan

Our goal
By 31st March 2012,
all people with dementia who are receiving antipsychotic
drugs will have undergone a clinical review to ensure that if
they are receiving these drugs they are doing so
appropriately & that alternatives to their prescription have
been considered & a shared decision has been agreed
regarding their future care

@helenbevan

Priority groups to call to action
• The clinical decision makers who prescribe & review
therapeutic interventions
• Those who we want to shift power to (e.g., people
with dementia & their carers)
• Those who can give voice & advocacy to people with
dementia & their carers
• Those with authority who can promote & ensure
best practice

@helenbevan

Call to action for pharmacists
I (we) commit to:
reviewing the people
under my care to identify
those who are prescribed
antipsychotic medication
& working in partnership
with my prescribing &
other healthcare
colleagues to review each
individual by 31st March
2012


What has happened?
51% reduction in the prescription of antipsychotic
drugs for people with dementia across England
Learning study:
Mobilising and organising for large scale change in healthcare
‘The Right Prescription: A Call to Action’
Manchester Business School
NHS Improving Quality
http://www.nhsiq.nhs.uk/media/2414209/dementia_report_nov
_2013.pdf
@helenbevan

The largest simultaneous
improvement
initiative in the history of
the NHS
@helenbevan

It started with a tweet!
Trainee doctors and
improvement leaders
started to talk about
how they could build a
social movement to
improve care
Damian Roland
Stuart Sutton
Helen Bevan
@helenbevan

A 189,000 pledge mountain!

86

@helenbevan

Example pledges
“We pledge to
introduce a test for
values and
behaviour for
recruitment into our
universities and into
employment.”
Health Education
England, West
Yorkshire

“As Director of Safety and Risk, my pledge is
to spend more time listening to patients and
staff and to act upon their concerns.” Moira
Durbridge
“We pledge to invite all individuals who make a
complaint about our services to be involved in
one of our 15 Steps Quality Challenge panels.”
Bradford District Care Trust, Yorkshire, 3001

“I pledge each month to contact a front line staff member
within my team who demonstrates inspirational clinical
practice.” East of England Ambulance Service NHS Trust
“I pledge to visit an elderly gentleman with
dementia in his own home to help him build his
life story on our Digital Reminiscence Therapy
Software.” Jo Samuels.

“I pledge to make sure every
person with a learning disability
at Turning Point has a health
action plan.” Fiona Ritchie

@helenbevan

People took action all over the country

@helenbevan

Probably the only
winner of a global
challenge to
develop leaders
in the corporate
world that names
Saul Alinsky and
Marshall Ganz as
major influencers

@helenbevan

Change Day 2013 was an extraordinary moment in the history
of the NHS. It taught us that large-scale improvement is
possible in the NHS and that the best way to do it is through
collective commitment, action and by keeping it simple.
@helenbevan

3rd March 2014
www.changeday.nhs.uk

@helenbevan

2. Build alliances
3. Work out what might
help others to change

@helenbevan

“Stages of change”
Transtheoretical model of behaviour change

Prochaska, DiClemente & Norcross (1992)
@helenbevan

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

@helenbevan

The model is mostly used around
health-related behaviours
•
•
•
•
•
•
•
•
•
•

smoking cessation
exercise adoption
alcohol and drug use
weight control
fruit and vegetable intake It works for
organisational and
domestic violence
HIV prevention
service change too!
use of sunscreens to prevent skin cancer
medication compliance
mammography screening

@helenbevan

Smoking

I am not aware my
smoking is a
problem – I have no
intention to quit

@helenbevan

Smoking

I am not aware my
smoking is a
intention to quit
I know my smoking
is a problem – I
want to stop but no
plans yet


@helenbevan

Smoking

I am not aware my
smoking is a
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.

@helenbevan

Smoking

I am not aware my
smoking is a
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!


@helenbevan

Smoking
I am continuing to
not smoke.
I sometimes miss it
– but I am still not
smoking

I am not aware my
smoking is a
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!

@helenbevan

90% of the tools available for healthcare change
agents are designed for the “action” stage
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
@helenbevan

Example - Surgical Checklist
• 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
@helenbevan

So what do we TEND to do?
• 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

@helenbevan

So what SHOULD we do?
• 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
@helenbevan

Task
Using the sheet that shows tactics at the
different stages of change, consider one or more
of the improvement initiatives that people at
our table are involved in:
• Who are the key people we need to get on
board?
• What stage of change are they at?
• How can I help them move to the next stage
of change?
@helenbevan

What happens to large scale
change efforts in reality?
In order of frequency:
1. the effort effectively “runs out of energy” and
simply fades away
2. the change hits a plateau at some level and no
longer attracts new supporters
3. 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
@helenbevan #Staffschange

Does fear motivate people to
change?


burning platform
versus
burning ambition
@PeterFuda


Lessons for transformational change
1. In order to sustain
transformational change we
need to move from a burning
platform (fear based urgency) to
a burning ambition (shared
purpose for a better future)
2. We need to articulate personal
reasons for change as well as
organisational reasons
3. If the fire (the compelling
reason) goes out, all other
factors are redundant
@PeterFuda


Task
Talk to the person next to you
• What is “my burning ambition” for my service, my
community and /or my patients?
• Try to make it personal: link it with your earlier
narrative; tell others why this ambition connects
with your personal motivations


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


Download for free at
www.changemodel.nhs.uk

@helenbevan

Energy for change is:
Spiritual

the capacity and
drive of a team,
organisation or
system to act
and make the
difference
necessary to
achieve its goals

Social

Psychological

Physical


Intellectual

Five energies for change
Energy

Definition

Social

Energy of relationships and connections between people:
people feel a sense of “us and us” rather than “us and them”

Spiritual

Energy of commitment to a common vision for the future:
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:
People feel confident to make a change and trust in leadership
and direction

Physical

Energy of action, getting things done and making progress:
the flexible, responsive drive to make things happen

Intellectual

energy of analysis, planning and thinking:
Planning and supporting processes, evaluation, arguing a case
on the basis of logic/ evidence

@helenbevan

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


Some questions
• Which group is likely to have higher spiritual
energy scores
 clinicians?
 non clinicians?

• The nearer I am in the hierarchy to the CEO, is
my overall energy score likely to be
 higher
 lower?

Energy for change profile
Social
5

4
3

Intellectual

2
1

Physical

• Are particular
energy domains
more dominant
than others for
Spiritual
our team at the
moment?
• Is this the
optimal energy
profile to help
us achieve our
Psychological
improvement
goals?

@helenbevan

Energy for Change
A case study
Michele Upton is
responsible for strategic
improvement across 17
neonatal units in the
East of England region.
A care bundle aimed at
reducing rates of
Necrotising Enterocolitis
(NEC) in premature
babies was implemented
across the 17 units. One
unit has been struggling
to maintain compliance
with the interventions.
Attempts to improve
compliance have been
ongoing for two years.
@helenbevan

Spiritual

Social

Psychological

Intellectual

Physical

Michelle received training on
the 5-Energy model.
The unit completed the
Energy for Change online
self-assessment which
revealed low physical and
spiritual energy for the
change within the team.

They also clarified their
shared purpose: for the
MDT to work together
better and use evidence
based practice.

The team discussed what was
depleting their energy – and
created an action plan to
build energy for the change –
based on building
commitment to the change.

Team 1: what’s your assessment of
their energy for change?
Social
5
4
3

Intellectual

Spiritual

2

1

Physical

Psychological

@helenbevan

This energy profile is

Social
5
4

3

Intellectual

2

Spiritual

1

Physical

Psychological

@helenbevan

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
5
4
3

Intellectual

Spiritual

2

1

Physical

Psychological

@helenbevan

This energy profile shows

Social
5
4

3

Intellectual

2

Spiritual

1

Physical

Psychological

@helenbevan

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

Where does team 1 go for help?

Roadmap of resources for
building energy for change

Task
Using the template, make an assessment of the
energy for change in the project you are working
on at present:
• Where are the opportunities to build a more
balanced set of energies?
• How might you go about doing this?

“You can’t impose anything
on anyone and expect them
to be committed to it”
Edgar Schein, Professor Emeritus
MIT Sloan School

@helenbevan @PowerNHS

What is our approach to change?
Compliance

Commitment

States a minimum performance
standard that everyone must
achieve

States a collective goal that
everyone can aspire to

Uses hierarchy, systems and
standard procedures for coordination and control

Based on shared goals, values
and sense of purpose for coordination and control

Threat of penalties/ sanctions/
shame creates momentum for
delivery

Commitment to a common
purpose creates energy for
delivery


Source: Helen Bevan

“ The source of energy at work is not in

control, it is in connection to
purpose”
Don Berwick, 28th February 2012


Shared purpose aligns.....
Shared purpose allows
many communities to
engage with us without us
having to invest resources
in controlling their actions

Nilofer Merchant


[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

@helenbevan @PowerNHS

A three word concept

@helenbevan

Change agent as “signal generator”
“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

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

@SimonJGuilfoyle Police Inspector and systems thinker
@helenbevan@RobertVarnam #IHI25Forum #ChangeAgents
@HelenBevan #Staffschange

Police


Education


Healthcare



143

How do we create shared purpose?

Create a safe
space

Look for
commonalities
& understand
differences


Create a
statement of
purpose

Task
In the context of your own change initiative:
• Who needs to be part of our shared purpose?
• What unites us?
• What is our actual shared purpose (ie, the
reason WHY we are undertaking the change)


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

@helenbevan

....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 inspire
Dov Seidman

@helenbevan

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

@helenbevan

How to Be a Great Change Agent - Minicourse M10

Recomendados

Recomendados

Mais conteúdo relacionado

Mais procurados

Mais procurados (20)

Destaque

Destaque (15)

Semelhante a How to Be a Great Change Agent - Minicourse M10

Semelhante a How to Be a Great Change Agent - Minicourse M10 (20)

Mais de NHS Improving Quality

Mais de NHS Improving Quality (20)

Último

Último (20)

How to Be a Great Change Agent - Minicourse M10

Notas do Editor