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

@HelenBevan @BoelGare @JackieLynton #Quality 2014 #M5
The School for Health and Care Radicals
Helen Bevan,
@Helen Bevan
NHS Improving Quality, England
Boel Andersson Gäre
@BoelGare
Jönköping County Council and the Jönköping Academy , Sweden;
Jackie Lynton
@jackieLynton
NHS Improving Quality, England

Why the School for Health & Care Radicals?
It’s tough being a change agent in health and care, particularly
when other people don’t always get it or want to change.
Yet big change happens in health and care only because of
heretics and radicals: passionate people who are willing to take
responsibility for change. We are people who support the goals
of our health and care systems, but also want to change
existing thinking and practice and improve care for patients
and people who use services.
The School for Health and Care Radicals provides tools, ideas
and connections with a community of radicals to help us thrive
and survive as agents of positive change

We are a learning community
• We encourage you to tweet during the day using the
hashtags #Quality2014 and #M5
• We hope other radicals will join in virtually during the
day
• We will produce a summary of the day using
Storify.com and send it to you

What is community?
1. Locality
2. Interest or shared purpose
3. Sense of belonging: “community spirit”
“There is no power for change greater than a
community discovering what it cares about.”
~ Margaret Wheatley
Source of image:
rootedincommunity.org

Power in community
“Power used to come largely through and from big
institutions.
Today power can and does come from connected individuals
in community.
When community invests in an idea, it co-owns its success.
Source of image: orton.org
Instead of trying to
achieve scale all by
ourselves, we have a new
way to have scale. Scale
can be in, with and
through community.”
Nilofer Merchant

Why am I a radical?

Task
Today you will be working as a community with
others on your table so it’s important to find out
who is in your community.
Introduce yourself to others at your table. Tell a
quick story that demonstrates why you chose to
come to this course today.
Time allowed: 15 minutes for the whole table

The genesis of the School
2002
2014
2013
2010
2012
2003
NHS Change Day
2013
“A school for
healthcare
radicals”
Applying
social movement
thinking to
healthcare
improvement
“The School for
Health and Care
Radicals”
“A one day school
for organisational
radicals”
Applying
community organising
principles to
healthcare
improvement

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

Source: @NHSChangeDay

The school is based on two kinds of learning
Transactional learning Transformational learning
A “toolkit” of ideas &
approaches
Learning through
motivation, practice &
feedback
Seeks to transfer useful
knowledge
Seeks to transform beliefs
& underlying assumptions
Learning event,
presentations & materials
Experiential, interactive &
action-based
Generates understanding of
“what to do”
Generates increased
capacity in “how to do it”
Source: Based on John Wenger https://medium.com/corporate-learning/3deb1bb2e865

What is happening in the world
of change?
Source of image: from guardiansprayerwarrior.com

Emerging themes in change and transformation
Source: @HelenBevan

John Kotter: “Accelerate!”
• We won’t create big change through hierarchy
on its own
• We need hierarchy AND network
• Many change agents, not just the usual few
• Changing our mindset
• From “have to” to “want to”
• Head and heart, not just head
Source of
image:www.slideshare.net/m
exicanwave/champions-trolls-
10-years-of-the-cipd-online-
community

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

is the new normal!
“By questioning existing ideas, by
opening new fields for action, change
agents actually help organisations
survive and adapt to the 21st Century.”
Céline Schillinger Image by
neilperkin.typepad.com

ACROSS THE WORLD,
THE CHANGE AGENT
MOVEMENT
IS EXPLODING!
@rebelsatwork
rebelsatwork.com
@chagww
changeagentsworldwide.com
@corprebels
corporaterebelsunited.com

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

#NHSChangeDay #SHCRchat@HelenBevan @BoelGare @JackieLynton #Quality 2014 #M5
Peter Fuda’s Transformational Change Agent
framework
Skills and methods for creating
change
Ability to make sense of, and reshape
perceptions of ‘reality’
Personal characteristics and
qualities

framework: my perspective
“Doing”
• Where most change agents
in health and care put most
of their effort and emphasis
• What others typically judge
us on
• What we often perceive we
need to do to add value
• What most change and
improvement courses focus
on

framework: my perspective
“Seeing ” and “Being”
• We can only do effective
“doing” if we build on strong
foundations of “seeing and
being”
• Change begins with me
• Hopeful futures, creative
opportunities and potential
• Multiple lenses for change
• See myself in the context of
my higher purpose

“Being” as a health and care radical
Personal characteristics and
qualities

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

We need to be boatrockers!
• Walk the fine line between
difference and fit, inside and
outside, rock the boat but
manage to stay in it
• Able to challenge the status
quo when we see that there
could be a better way
• Conform AND rebel
• Capable of working with others
to create success NOT a
destructive troublemaker Source: Debra Meyerson

What are the risks for a boat rocker?
1. Our experiences of “being different” can be
fundamentally disempowering. This can lead us to
conform because we see no other choice
 we surrender a part of ourselves, and silence
our commitment, in order to survive
2. leave the organisation
 we cannot find a way to be true to our values
and commitments and still survive
3. stridently challenge the status quo in a manner
which is increasingly radical and self-defeating
 this just confirms what we already know – that
we don’t belong Source: adapted from Debra E Meyerson

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

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

Source : Lois Kelly www.rebelsatwork.com
Sometimes other people see radicals/rebels
as troublemakers
Rebel

Discussion
• What are your insights around
“rebels/radicals” and “troublemakers”?
• What moves people from being “rebel” to
“troublemaker”?
• How do we protect against this?

Valuing radicals
• “New truths begin as heresies” (Huxley, defending
Darwin’s theory of natural selection)
• Big things only happen in organisations because of
heretics and radicals.
GALILEO DESCRIBES HIS DISCOVERIES TO THE CHURCH ESTABLISHMENT

#NHSChangeDay #SHCRchat
"There’s only one
corner of the
universe you can
be certain of
improving, and
that’s your own
self."
Aldous Huxley
Source of image: timcoffeyart.wordpress.com

Source: via @NeilWigg

History tells us that personal
transformation comes before
organisational or system transformation
If we want to play our role, we have to focus
deeply on our own perspective and the ways
http://blogs.bmj.com/quality/2013/08/19/a-call-to-action-helen-bevans-blog-2/
we interact with and influence
others. The more that we can
unleash that powerful reservoir
of energy for change, the more
our influence and impact will
grow.
Image from novamagazine.com

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

1. Driven by conviction and values
2. strong sense of “self-efficacy”
 belief that I am personally able to create the change
3. able to join forces with others to create action
4. able to achieve small wins which create a sense
of hope, self-efficacy and confidence
5. More likely to view obstacles as challenges to
overcome
Five things we know about successful
boat rockers
Source: adapted from Debra E Meyerson
CHANGE
me
BEGINS WITH

Self-efficacy
There is a positive, significant
relationship between the
self-efficacy beliefs of a
change agent and her/his
ability to facilitate change
and get good outcomes
Source of image:www.h3daily.com

What’s the difference between
self efficacy
and
self esteem,
self belief,
self-confidence?

What is the issue here?
“permission” ?
(externally generated)
or
Self efficacy ?
(internally generated)

Brainstorm at the table
What are some ways that health and care
radicals can build self-efficacy?

Building self-efficacy: some tactics
1. Invest in your own change agent development
• create the conditions where success is more likely to happen
2. Create change one small step at a time
3. Reframe your thinking:
• failed attempts are learning opportunities
• uncertainty becomes curiousity
4. Make change (and learning cycles from change) routine
rather than an exceptional activity
5. Get social support
6. Learn from the best
7. Get people whose opinions you value to encourage you
(mentor?)

“Being an effective Change Agent involves
demonstrating what you
teach as much as pontificating from the
mountaintops. Any behaviour we ask
others to adopt, we must consistently
represent in our own work, and share the
positive outcomes.”
Bryce Williams
Working Out Loud
Source of image: leighellis.net

1. Driven by conviction and values
2. strong sense of “self-efficacy”
 belief that I am personally able to create the change
3. able to join forces with others to create action
4. able to achieve small wins which create a sense of
hope, self-efficacy and confidence
5. More likely to view obstacles as challenges to
overcome
Five things we know about successful
boat rockers
Source: adapted from Debra E Meyerson
CHANGE
me
BEGINS WITH

Source of image:
outskirtsbattledome.wik
ispaces.com
The easiest way to thrive as an
outlier
...is to avoid being one
Seth Goodin

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

Learning from social movement leaders

Call to Action
Source: @RobertVarnam

How do we create change at scale?
Source: Marshall Ganz
Shared understanding leads to
Action
Narrative
why?
Strategy
what?

What is strategy?
Strategy is the process of turning
the you have into
the you need to win
the you want

Resources to improve health and care
Economic resources
diminish with use
• money
• materials
• technology
Natural resources
grow with use
• relationships
• commitment
• community
Based on principles from Albert Hirschman, Against Parsimony

Framing
… is the process by which leaders construct,
articulate and put across their message in a powerful
and compelling way in order to win people to their
cause and call them to action.
Snow D A and Benford R D (1992)

What’s the
financial incentive?
Who is
performance
managing?
What’s the
project plan?

The reality
“What the leader cares about (and typically bases at
least 80% of his or her message to others on) does
not tap into roughly 80% of the workforce’s primary
motivators for putting extra energy into the change
programme”
Scott Keller and Carolyn Aiken (2009)
The Inconvenient Truth about Change Management
Source of image: swedenbourg-openlearning.org.uk

“I have some Key
Performance
Indicators
for you”
or
“I have a
dream”

Leaders ask their staff to be ready for change,
but do not engage enough in
sensemaking........
Sensemaking is not done via marketing...or
slogans but by emotional connection with
employees
Ron Weil

How the world of work is shifting
• The organisation as a
collective
• Leaders seek to build
the allegiance of the
workforce to the goals,
culture and ethos of the
organisation
• The network as a
connective
• We share and identify
with a deeper, extra-
corporate work culture
and the structure is
subordinated to that
Source:stoweboyd.com
Source of image: www.slideshare.net/mexicanwave/champions-trolls-10-years-of-the-cipd-online-community

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

But not all emotions are equal.........
inertiaurgency
anger apathy
solidarity isolation
you can make a
difference
Self-doubt
hope fear
Overcomes
Action motivators Action inhibitors

Effective framing:
what do we need to do?
1. Tell a story
2. Make it personal
3. Be authentic
4. Create a sense of “us” (and be clear who the “us”
is)
5. Build in a call for urgent action

Creating our narrative
• Challenge: What was the challenge? Why was
it a challenge?
• Choice: What were the choices? Why did you
make the choice you did? Where did you get
the courage or hope? How did it feel?
• Outcome: How did the outcome feel? Why did
it feel that way? What do you want us to feel?

Vivid details

Talk to the person next to you
• Tell your story about why the change you are
involved in now is so important to you
• Relate it to a personal experience
You have:
• 2 minutes to prepare your story
• 2 minutes each to tell your story

Talk to the person next to you
Have a further discussion
• In terms of the people you want to get on
board with your change project, what will
create a sense of “us” rather than “us and
them”?
• How could telling your story help create the
“us”?
You have three minutes for further discussion as
a pair

Talk to the rest of the table
What insight did you get from that exercise?
You have five minutes for a whole table
discussion

How do we create a
sense of “us” to build
momentum for
change?
Source of image:
studentblognmaestics.blogspot.com

strong ties (cohesive)
v.
weak ties (disconnected)
Source of image:brucemacvaresh.com

When we spread change through strong ties:
• we interact with “people like us”, with the same
life experiences, beliefs and values
• Change is “peer to peer”; GP to GP, nurse to
nurse, gynaecologist to gynaecologist
• Influence is spread through people who are
strongly connected to each other, like and trust
each other

When we spread change through strong ties:
• we interact with “people like us”, with the same
life experiences, beliefs and values
• Change is “peer to peer”; GP to GP, nurse to
nurse, gynaecologist to gynaecologist
• Influence is spread through people who are
strongly connected to each other, like and trust
each other
IT WORKS BECAUSE: people are far
more likely to be influenced to
adopt new behaviours or ways of
working from those with whom they
are most strongly tied

The pros and cons of strong ties
Pros Cons

Strong and weak ties
When we seek to spread change
through strong ties:
• we interact with “people like
us”, with the same life
experiences, beliefs and
values
• Change is “peer to peer”; GP
to GP, nurse to nurse,
gynaecologist to
gynaecologist
• Influence is spread through
people who are strongly
connected to each other, like
and trust each other
When we seek to spread change
through weak ties:
• we build bridges between groups
and individuals who were previously
different and separate
• we create relationships based not
on pre-existing similarities but on
common purpose and
commitments that people make to
each other to take action
• our aim is to mobilise all the
resources in our organisation,
system or community that can help
achieve our goals

Why we need to build weak ties
AS WELL AS strong ties
• Weak ties are more likely to lead to change at scale because they
enable us to access more people with fewer barriers

• In situations of uncertainty, we have a tendency to revert to our
strong tie relationships
• yet the evidence tells us that weak ties are much more
important than strong ties when it comes to searching out
resources in times of scarcity

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

• The most breakthrough innovations will come when we tap into
our weak ties
History suggests that weak ties will probably give us the best
chance to deliver large scale improvements in a challenging
timescale

Three components of a great
narrative
• Diagnostic – what is the problem that we are
addressing? What is the extent of the problem?
What is the specific source or sources?
• Prognostic – what could the future look like? What is
our “plan of attack” and our strategy for carrying out
the plan?
• Motivational – why is this urgent? What is our call
for action that connects with the motivational and
emotional drivers of the audience?
Source: Benford and Snow

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

“A cynic, after all,
is a passionate
person who does
not want to be
disappointed
again.”
Zander R and Zander B (2000) The art of
possibility. Harvard Business School Press. As
quoted by Steve Onyett

Who are your communities?
Source: Celine Schillinger http://weneedsocial.com/blog/2013/8/25/disrupted-disruptors-unite
• In your role: through relationships and social
networks
• Through external social networks such as
Twitter and LinkedIn
• Through communities of practice and learning
groups

82
http://weneedsocial.com/blog/2013/8/25/disr
upted-disruptors-unite

The most effective change agents:
• don’t waste their time and energy
blaming and complaining
• take calculated risks to achieve the
outcomes they sought
Now is the time to plan steps to keep
moving myself forward, with positive
momentum, as a health and care radical

Three assumptions for health and care radicals
1. Assume that everyone has a noble intention.
2. When people “resist” change is it more likely
to be a result of their interpersonal
interaction with the change process than
their innate character traits (“a bad change
process not a difficult person”).
3. My role as a change agent is about
alignment, not judgement.
Source of image:help.adobe.com

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

“Being” as a health and care radical
CHANGE
me
BEGINS WITH
• Living my conviction and values
• Strong sense of “self-efficacy”
 belief that I am personally able to create the
change
• Shared purpose, not de facto purpose
• Stepping outside my comfort zone
• A “rebel” rather than a “troublemaker”
• Learning not judging

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

“Seeing” as a health and care radical
Ability to make sense of,
and reshape perceptions of
‘reality’

‘En este muno traidor
No hay verdad ni mentira,
Que todo esta en el color
Del cristal con que se mira’
In this world of many mazes
There is nothing false or true:
All depends upon the hue
Of the glass through which one gazes
(Sixteenth-century Spanish quatrain)

Seeing
“Seeing, looking, monitoring, listening,
perceiving and especially the indefinite concept
of intuitive feeling ”
Aubrey Jango

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

What do we mean by
resistance to change?

#NHSChangeDay #SHCRchat#NHSChangeDay #SHCRchat
Source of image: sport-fitness-advisor.com
Any force that stops or
slows movement
Resistance

Employee resistance is the
most common reason
executives cite for the
failure of big
organizational-change
efforts
Scott Keller and Colin Price
(2011), Beyond Performance: How
Great Organizations Build Ultimate
Competitive Advantage
Source of image:
Businessconjunctions.com

Change can either
challenge or
threaten us…….
Your beliefs pave
your way to success
or block you
Marsha Sinetar
Source of image:
Creatememe.chucklesnetwork.com

Diagnostic
and
dialogic
approaches
to
resistance to change

• Change is something that happens “out there”
in the organisation or system
• Resistance is a force to overcome
• Resistance prevents change
• Change agents must diagnose, manage and/or
overcome resistance
• Resisters may be otherwise known as
“laggards”, “blockers”, “in denial”
Resistance: a “diagnostic” approach

Resistance to change

“The role of the change agent is to
recognise the causes of resistance and
address each one. If this is not done,
then the change will be much harder to
implement successfully and may not
succeed at all”
David Stonehouse
The change agent: the manager’s role in change
British Journal of Healthcare Management, Vol. 19, Iss.
9, 09 Sep 2013, pp 443 - 445
Diagnostic: the role of the change agent

• People make their own reality
• Change results from transformational
conversations
 involving more and different people in change discussions
 altering how and which people engage with each other
 by stimulating different perspectives to shape how people
think about things
• Resistance is an inevitable consequence of a
complex change process (based on diversity)
• Resistance should be embraced and worked with
Resistance: a “dialogic” approach

1. Create the conditions for transformational
conversations by asking questions that are focussed
on future possibilities, by inviting diversity into the
system, and by being welcoming
2. Creat-e opportunities for everyone to express their
views, spot opportunities and build on each other’s
ideas
3. Create ways for people to reflect together to find
meaning, understanding and shared purpose in the
change
Source: Peggy Holman
Dialogic: the role of the change agent

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

“Leaders and organisations must let go of the idea
that there is “one right way” and instead focus on
creating a learning culture where people feel
accepted, are comfortable contributing ideas, and
actively seek to learn from each other”
Diaz_Uda, Medina and Schill (2013)
Source of image:fineartamerica.com
Health and care radicals should be champions
of diversity for change

In the context of “rolling with resistance”
• What are the implications of embracing diversity
of thought, experience and background in our
change efforts?
• What skills and perspectives do health and care
radicals need to work effectively with diverse
teams for change?
Source of image:fineartamerica.com
Discussion

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

• Helen’s intent was to give people quick
solutions, help them do their work faster
and get on to the next problem at hand
• However, her impact was that people did
not know how to solve their own
problems so that Helen’s style was
impeding their development
Source: adapted from Intent vs. Impact: A Leadership Lesson by Claudia Busch Lee
Source of image: thedigitalawards.com

Stop talking
AT ME
Start talking
TO ME Source of image: prepbeijing.com

• Build a trusting and supportive work
environment
• Listen with an open heart and open mind
• Commit to the change 100%
• Seek common purpose and common
interests
• Take time to build relationships
• Be open with my intent
• Take responsibility for my own actions
What should I do to manage intent and
impact?

If your horse dies,
get off it
Cherokee proverb
Source of image: fenwickgallery.co.uk

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

“Stages of change”
Transtheoretical model of behaviour change
Prochaska, DiClemente & Norcross (1992)

The model is mostly used around
health-related behaviours
• smoking cessation
• exercise adoption
• alcohol and drug use
• weight control
• fruit and vegetable intake
• domestic violence
• HIV prevention
• use of sunscreens to prevent skin cancer
• medication compliance
• mammography screening

The model is mostly used around
health-related behaviours
• smoking cessation
• exercise adoption
• alcohol and drug use
• weight control
• fruit and vegetable intake
• domestic violence
• HIV prevention
• use of sunscreens to prevent skin cancer
• medication compliance
• mammography screening
It works for
organisational and
service change too!

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

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

Transtheoretical model of behaviour change

• Which stage do most change activities in
health and care focus on?
• Which stage are most people actually at?
Some questions

The reality of our change situation
• Our tools are often not effective at the stage of change
that most people we work with are at
• It’s hard to engage people in change
• It’s hard to get people to make the changes we want
them to make
• People get irritated, defensive, irrational
• We feel powerless in our ability to lead or facilitate the
change
90% of the tools available for health and care change
agents are designed for the “action” stage

• Designed for Stage 4
– ACTION!
• Mandated it through
targets
• Despite compelling
case for change –
people resisted it –
no values connection
• People did the task
and missed the point
Example - Surgical Checklist

• Lower our ambitions for improvement
• Focus our energies on those who are
already in the “action” stage
• Put negative labels on those who are
not yet at the action stage such as
“blocker” or “resister” or “laggard”
• Blame “the management” for not
enforcing change
So what do we TEND to do?

The single biggest problem
in communication is the
illusion that it has taken
place
George Bernard Shaw

• Listen and understand
 appreciate the starting point
 elaborate interests
• Build meaning and conviction in the change
• Roll with resistance (Singh)
 Don’t argue against it
 Encourage elaboration of resistance
• What makes it so hard?
• What would help?
• Build shared purpose
So what SHOULD we do?

• The focus should be on
creating awareness for me of
the need to change
• Remember the goal is not to
make me (as a
precontemplator) change
immediately, but to help me
move to contemplation
• I am not thinking about
changing my behaviours,
actions or work processes
• The problem or issue is
outside my frame of
awareness or my perceived
need

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

“Seeing” as a health and care radical
• The big picture
• Multiple perspectives
• The positive intentions of others
• Possibility of bad change processes rather than
resistors, blockers and laggards
• Hopeful futures, creative opportunities and
potential
• Multiple paradigms for change (eg, diagnostic and
dialogic)
• See myself in the context of my higher purpose

“Doing” as a health and care radical
Skills and methods for
creating change

Most large scale change doesn’t fully
deliver its objectives
Source: McKinsey Performance Transformation Survey, 3000 respondents to
global, multi-industry survey
70%
25%
5%
Gets anywhere near
achieving the
change and
delivering the
benefits

Most large scale change doesn’t fully
deliver its objectives
Source: McKinsey Performance Transformation Survey, 3000 respondents to
global, multi-industry survey
70%
25%
5% Delivers and
sustains the change

Image from: @TheWorldStories

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

What happens to large scale
change efforts in reality?
In order of frequency:
1. the effort effectively “runs out of energy” and
simply fades 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

Leaders as “signal generators”
“As a leader, think of yourself as a “signal generator”
whose words and actions are constantly being
scrutinised and interpreted, especially by those
below you *in the hierarchy+”
“Signal generators reduce uncertainty and ambiguity
about what is important and how to act”
Charles O’Reilly, Leaders in Difficult Times, 2009

Front line teams get inundated with high priority
messages from leaders each day, making it
difficult for them to know what to focus on
Increasing number of messages
as information cascade through
the organisation
Source: adapted from
http://businessjournal.gallup.com/content/162707/change-initiatives-fail-
don.aspx

Front line teams get inundated with high priority
messages from leaders each day, making it difficult for
them to know what to focus on
Increasing number of messages
as information cascade through
the organisation
Source: adapted from
http://businessjournal.gallup.com/content/162707/change-initiatives-fail-
don.aspx
Buy in from front line staff is critical for
improvements in quality and safety . Don’t
overload them
Buy in from front line staff is critical
for improvements in quality and safety
Don’t overload them
http://healthaffairs.org/blog/2014/03/07/the-
dangers-of-quality-improvement-overload-insights-
from-the-field/

Typically, around any change effort, there is an
initial spike of tangible energy, and change, but
when leadership loses interest, the momentum
of change slows down drastically.”
Tara Paluck

Ten key principles of large scale change
1. Movement towards a new vision that is better and
fundamentally different from the status quo
2. Identification and communication of key themes that people
can relate to and that will make a big difference
3. Multiples of things (‘lots of lots’)
4. Framing the issues in ways that engage and mobilise the
imagination, energy and will of a large number of diverse
stakeholders in order to create a shift in the balance of power
and distribute the leadership
5. Mutually reinforcing change across multiple
processes/subsystems

6. Continually refreshing the story and attracting new, active
supporters
7. Emergent planning and design, based on monitoring progress
and adapting as you go
8. Many people contribute to the leadership of change, beyond
organisational boundaries
9. Transforming mindsets, leading to inherently sustainable
change
10. Maintaining and refreshing the leaders’
energy over the long haul
Ten key principles of large scale change

Intrinsic
motivation
People engage in the
activity for the
pleasure and
satisfaction of doing it
Invokes many positive
behaviours
Extrinsic
motivation
People engage in the
activity for the
rewards or avoiding
punishment
Any external
influence is referred
to as extrinsic
motivation
Source:
http://www.slideshare.net/JeremyStephens103/coaches-as-extrinsic-motivators-
and-supporter-of-intrinsic-development

Transformation is not a matter of
intent.........
it is a matter of alignment
Peter Fuda

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

“Take your
passion and
make it
happen”
Source of image: www.zeelandtheaters.nl

Discussion
Reflecting on your change process:
• how have you built both intrinsic and extrinsic
motivators of change into your efforts?
• How have you managed the tension between
the two?
• Any advice for other change agents on how to
align intrinsic and extrinsic motivators?

Research shows that more than almost
any other factor affecting an
organisation, organisational energy can
lead to either a wellspring of corporate
vitality or the destruction
of its very core
Source: Bruch and Vogel

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

the capacity and
drive of a team,
organisation or
system to act
and make the
difference
necessary to
achieve its goals
Psychological
Physical
Spiritual
Social Intellectual
Energy for change is:

Five energies for change
Energy Definition
Social energy of personal engagement, relationships and connections
between people. It’s where people feel a sense of “us and us”
rather than “us and them”
Spiritual energy of commitment to a common vision for the future, driven
by shared values and a higher purpose. It gives people the
confidence to move towards a different future that is more
compelling than the status quo
Psychological energy of courage, resilience and feeling safe to do things
differently. It involves feeling supported to make a change and
trust in leadership and direction
Physical energy of action, getting things done and making progress. It is
the flexible, responsive drive to make things happen
Intellectual energy of analysis, planning and thinking. It involves gaining
insight as well as planning and supporting processes, evaluation,
and arguing a case on the basis of logic/ evidence

High and low ends of each energy domain
Low High
Social isolated solidarity
Spiritual uncommitted higher purpose
Psychological risky safe
Physical fatigue vitality
Intellectual Illogical reason

• Are particular
energy domains
more dominant
than others for
our team at the
moment?
• Is this the
optimal energy
profile to help
us achieve our
improvement
goals?
Energy for change profile
1
2
3
4
5
Social
Spiritual
PsychologicalPhysical
Intellectual

1
2
3
4
5
Social
Spiritual
Intellectual
Team 1: what’s your assessment of
their energy for change?

1
2
3
4
5
Social
Spiritual
Intellectual
their energy for change? This energy profile is
characterised by an
environment that has
harnessed people’s
interest and momentum
for change, but which has
failed to engage people
fully. This imbalance
results in their feeling
some uncertainty
regarding how they can
contribute fully to the
change, and therefore a
sense of risk and lack of
hope for the future. We
can build energy by
building team solidarity
and developing shared
purpose

1
2
3
4
5
Social
Spiritual
Intellectual

1
2
3
4
5
Social
Spiritual
Intellectual
This energy profile shows
strong connections
between people, a true
sense of solidarity, which
gives them enough hope
for the future, but this
energy is
undirected, because the
rational argument and
shared purpose has not
been agreed. We can
build energy by agreeing
shared goals for change
and using systematic
approaches to thinking
through and planning the
change

There has never been a time in the history
of healthcare when this advice has been
more pertinent
“Leadership is not about making clever
decisions and doing bigger deals. It is
about helping release the positive energy
that exists naturally within people”
Henry Mintzberg

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

#NHSChangeDay #SHCRchat@HelenBevan @BoelGare @JackieLynton #Quality 2014 #M5 Source: Helen Bevan
Compliance
States a minimum performance
standard that everyone must
achieve
Uses hierarchy, systems and
standard procedures for co-
ordination and control
Threat of penalties/ sanctions/
shame creates momentum for
delivery
What is our approach to change?
Commitment
States a collective goal that
everyone can aspire to
Based on shared goals, values
and sense of purpose for co-
ordination and control
Commitment to a common
purpose creates energy for
delivery

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

We know that ...
• Shared purpose is a common thread in successful
change programmes*
• Organisations and change initiatives with strong
shared purpose consistently outperform those
without it.**
*What makes change successful in the NHS? Gifford et al 2012 (Roffey Park Institute)
**Management Agenda 2013 Boury et al (Roffey Park Institute)

A 3-word concept

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

Avoiding “de facto” purpose
• What leaders pay attention to matters to staff, and consequently
staff pay attention to that too
• Shared purpose can easily be displaced by a “de facto” purpose:
 hitting a target
 reducing costs
 reducing length of stay
 eliminating waste
 completing activities within a timescale
 complying with an inspection regime
• If purpose isn’t explicit and shared, then it is very easy for
something else to become a de facto purpose in the minds of the
workforce
Source: Delivering Public Services That Work: The Vanguard Method in the Public Sector

@SimonJGuilfoyle Police Inspector and systems thinker

Police

Education

Healthcare

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

“Doing” as a health and care radical
• Create the conditions where everyone
can contribute and do their best
• Join forces with others to create action
• Achieve small wins which create a sense of
hope, self-efficacy and confidence
• Appeal to both the head (logic/planning/data) and
the heart (shared
values/purpose, framing, relationships)
• Make change (and learning cycles from change)
routine rather than an exceptional activity
• Use models, theories and frameworks effectively

‘I do not think you can really deal with
change without a person asking real
questions about who they are and how they
belong in the world’
David Whyte, The Heart Aroused 1994
Source of image: fistfuloftalent.com

We have a choice
“This is the true joy of life, the being used up for a
purpose recognised by yourself as a mighty
one, being a force of nature instead of a
feverish, selfish little clot of ailments and
grievances, complaining that the world will not
devote itself to making you happy.”
George Bernard Shaw

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

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