Leading large scale change: a practical guide

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Leading large scale change
an ILN Virtual Thursday
Source of image: @voinonen

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The Horizons team:
Change agents and change agency
• A small, diverse team of people within
the English National Health Service
• We tune into the latest change thinking
and practice in healthcare and other
industries around the world –
translating this learning into practical
approaches to change
• The team has emerged through years of supporting
change in the NHS and the wider health and care system

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The NHS is the 5th biggest employer
on the globe
Source: BBC= 100,000 employees

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4
https://www.england.nhs.uk/wp-content/uploads/2017/09/practical-guide-large-scale-change-nov17.pdf

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“Organising for scale may be the
biggest challenge we face in
improvement“
Don Berwick

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Beware the chasm!
Source of image: @voinonen

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8
The greatest
danger today is NOT
micro-managing:
it is MACRO-LEADING
Henry Mintzberg

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Change is changing

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Kinthi Sturtevant, IBM
13th annual Change Management
Conference
We rarely see two, three or
four year change projects
any more. Now it’s 30-60-90
day change projects

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Connect with the 3%
Just 3% of people in the organisation or
system influence 85% of the other people
Source: research by Innovisor

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The 3% rule also appears true for
social media
Source: research by Graham MacKenzie using NodeXL
In health and
healthcare globally,
tweets by 3.3% of
tweeters accounted
for 85% of retweets

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Most social media operates within an
echo chamber
Source of image: Scriberia

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The powerful medical “superconnectors”
Source: NodeXL analysis:

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We still organise the public sector like the
Tabulating Machine Co. of 1917
Source of image: @corp_rebels

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Source: Innovisor

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Three time points of collaboration among
cancer clinicians and researchers
from Braithwaite and colleagues 2017

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Source: World Economic Forum goo.gl/VDSnhA

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Collaborative innovation methods (“at the
edge”) are outpacing traditional R&D
Source: PWC Innovation benchmarking survey 2017

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Why go to the edge?
“ Leading from the edge brings us
into contact with a far wider range
of relationships, and in turn, this
increases our potential for diversity
in terms of thought, experience and
background. Diversity leads to more
disruptive thinking, faster change
and better outcomes
Aylet Baron

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The model for large scale change
26

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It’s an issue of power
Power is one’s
ability to achieve
goals
Bertrand Russell

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Jeremy Heimens, Henry Timms
This is New Power
old power new power
Currency
Held by a few
Pushed down
Commanded
Closed
Transaction
Current
Made by many
Pulled in
Shared
Open
Relationship

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WHO will make the change happen?
List A
• The Delivery Board
• The senior sponsors
• The Programme
Management Office
• The Delivery Board work
streams
• The Working Groups
• The Directors of
participating organisations
• The Change Facilitators
Source: adapted by Helen Bevan
from Leandro Herrera

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List A
• The senior sponsors
• The Programme
Management Office
streams
• The Working Groups
List B
• The mavericks and rebels
• The deviants (positive). Who do
things differently and succeed
• The nonconformists who see
things through glasses no one else
has
• The hyper-connected who spread
behaviours, role model at a scale,
set mountains on fire and multiply
anything they get their hands on
• The hyper-trusted. Multiple
reasons, doesn’t matter which
onesSource: adapted by Helen Bevan

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List A
• The programme sponsors
• The Programme
Management Office
streams
• The Clinical Leads
List B
• The mavericks and rebels
• The deviants (positive). Who do
things differently and succeed
• The nonconformists who see
things through glasses no one else
has
• The hyper-connected who spread
behaviours, role model at a scale,
set mountains on fire and multiply
anything they get their hands on
• The hyper-trusted. Multiple
reasons, doesn’t matter which
ones
Source: adapted by Helen Bevan

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What’s the evidence?
The failure of large scale
transformational change projects is
rarely due to the content or
structure of the plans that are put
into action
To make transformational change
happen we need to connect networks
of people who ‘want’ to contribute
http://iedp.com/articles/vertical-leadership/?utm_source=Sign-Up.to&utm_medium=email&utm_campaign=13787-
257163-Campaign+-+01%2F09%2F2016
Source: David Dinwoodie (2015)
It’s much more about the role
of informal networks in the
organisations and systems
affected by change

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Do you remember that 3% of people in an
organisation influence 85% of other
people?
Most of them are NOT people on list A
Formal leaders typically make up 12% of an
organisation and drive conversations with
55% of other people
Source: Innovisor

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Mark Jaben on the science behind resistance
What NOT to do
But what we do do
Engage
people here

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Mark Jaben on the science behind resistance to change
What NOT to do
(but what we usually do)
We don’t need buyers (who “buy-in” to change)
We need investors
What TO do
Engage
people here
Engage
people here

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The predominant approach in recent years has been STRUCTURE
but globally there is a big shift towards AGENCY
The design dilemma at the heart of change
Systemic approaches
Performance goals
Regulation
Competition
Programme
Management
Incentive systems
Activation
Ability to make choices
Capability
Leaders everywhere
Social action
Solidarity
Social movements

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Making sure that only people
who should be in hospital are
in hospital
• The number of hospital beds occupied by
patients whose transfer of care has been delayed
should be reduced to 3.5%
• Less than 15% of assessments [for continuing
care] should take place in an acute hospital
setting;
• a standardised performance dashboard

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Royal Devon and Exeter Hospital

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University Hospitals Morecombe Bay

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East Sussex Healthcare

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Individual AND collective agency
Individual agency:
People get more power
and control in their own
lives: activation, shared
decision-making and self-
care
Collective agency:
People act together,
united by a common
cause, harnessing the
power and influence of
the group and building
mutual trust

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“Because we want to, not because we have to”

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#endpjparalysis: connected social
communities

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Building agency for large scale change
We do not become transformed alone, we
become transformed when we’re in relationship
with others
Hahrie Han
Source of image: Idahoc Community Action

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New Public
Passion:
a growing
global
movement

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http://biggerboat.org/exploring-moodocs/
MOODOCs
(Massive, Online, Open, Disease Oriented Communities)
50

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Big drive to bring social movement thinking
and practice into delivery
51

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The era of the PLATFORM
Platforms today power learning and innovation
at the speed of change by providing
collaborative and sometimes exponentially
productive spaces for people to create value
John Hagel
Source of image: Pinipa

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We are witnessing the collapse of expertise
and rise of collaborative sensemaking
David Holzmer
Source of image: ACCA

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The implosion of trust
Source: http://www.edelman.com/news/2017-edelman-trust-barometer-reveals-global-implosion /
54
Peers are now as credible as experts

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• systematic “change
management”
• too often, leaders
prescribe outcome
and method of change
in a top-down way
• change is experienced
by people at the front
line as “have to”
(imposed) rather than
“want to” (embraced)
Change
Programmes
• everyone (including
service users and families)
can help tackle the most
challenging issues
• value diversity of thought
• connect people, ideas and
learning
• Role of formal leaders is to
create the conditions and
get out of the way
Change
Platforms
“Tear down the walls”

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What is the best way to spread new
knowledge?
Source of data: Nick Milton
http://www.nickmilton.com/2014/10
/why-knowledge-transfer-
through.html
Social connection/discussion is
14 times more effective
than
written word/best practice
databases/toolkits etc.
Source of image: www.happiness-one-quote-time.blogspot.com

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#NurseFuture nhs70.crowdicity.com

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Google image
search using the
word ‘nurse’
Google image
search using the
word ‘doctor’

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The Change Challenge
Tapping the collective brilliance
of the NHS

14,000 contributions identified
10 barriers to change:
Confusing strategies
Over controlling
leadership
Perverse incentivesStifling innovation
Poor workforce
planning
One way
communication
Inhibiting
environment
Undervaluing staff
Poor project
management
Playing it safe

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A global survey by Gallup into the reasons why
change initiatives fail, identified the same issue
Increasing number of messages
as information cascade through
the organisation
Source: adapted from
http://businessjournal.gallup.com/content/162707/change-initiatives-fail-
don.aspx

14,000 contributions identified
11 building blocks for change:
Inspiring & supportive
leadership
Collaborative working
Thought diversityAutonomy & trust
Smart use of resources
Flexibility &
adaptability
Long term thinking
Nurturing our people
Fostering an open
culture
A call to action
Source: Health Service Journal, Nursing Times, NHS Improving
Quality, “Change Challenge” March 2015
Challenging the
status quo

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After years of intensive analysis,
Google discovered that the key to high
performing teams that deliver change is
being nice
Project Aristotle:
https://www.youtube.com/watch?v=UfGiCnhdU78&feature=youtu.be&list=PLHEw3ja-
xoaZybvz9f0b1_6bJyG7zZO6L

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1. Frame issues in ways that will engage and mobilise the
imagination, energy and will of a large number of diverse
stakeholders
2. Take steps to be social leaders, investing in digital skills and
social connections and leading through networks as well as
formal leadership systems
3. Align structure and agency
4. Find your B-listers and give them important tasks
5. Make space for collective sensemaking: build change
platforms for important issues
6. Harness the power of advanced analytics
7. Adopt emergent approaches to planning and design, based
on monitoring progress, learning and adapting as you go
Ideas for
65

Leading large scale change: a practical guide

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