SHCR 2015 module 4

#SHCR @School4Radicals
http://www.theedge.nhsiq.nhs.uk/school/
Module 4:
Making change happen
Supported by

Joining in today and beyond
 Please use the chat box to contribute continuously during the
web seminar
 Please tweet using hashtag #SHCR and the handle
@School4Radicals
 Join our Facebook group School for Health and Care Radicals
 We will produce summaries of the discussions on each module
using Storify and Pinterest and put on the website
 Join in the Tweetchat each Wednesday at 4-5pm (GMT) using
the hashtag #SHCR

The team today
Session lead:
Helen Bevan
@HelenBevan
Learning lead:
Pip Hardy
@PilgrimPip
Icebreaker and
chat monitor:
Dominic Cushman
@domcushnan
Case study:
Jenny Clarke
@JennytheM
Twitter monitor:
Kate Pound
@kateslater2

 Why change efforts often fail to achieve their
objectives
 Leading large scale change
 The Change Model: aligning intrinsic and extrinsic
motivators for change
 Discussion on intrinsic/extrinsic motivators
 Building energy for change
 Creating shared purpose
 Discussion and reflection
Source of image: www.freshnessmag.com
for
today

Harvard researchers put a gorilla image on this lung scan

What proportion of the radiologists who
reviewed this scan actually saw the gorilla?
90%
25% 17%
80%
9%
60%

What proportion of the radiologists who
reviewed this scan actually saw the gorilla?
90%
25% 17%
80%
9%
60%
http://www.npr.org/blogs/health/2013/02/11/171409656/why-
even-radiologists-can-miss-a-gorilla-hiding-in-plain-sight

#SHCR @School4Radicals Source of image: Whatsthebigideascwartzy.blogspot.com

Icebreaker: Making change happen
 Which of these are you most interested
in finding out about today?

Most change programmes fail to
deliver their 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

Source: McKinsey Performance Transformation Survey, 3000 respondents to
global, multi-industry survey
70%
25%
5% Delivers and
sustains the change
Most change programmes fail to
deliver their objectives

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

As leaders, we are “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
Source of image:
vintage-radio.com

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
http://www.slideshare.net/NHSIQ/leading-large-scale-change-part-1

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
http://www.slideshare.net/NHSIQ/leading-large-scale-change-
part-1

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
Images: pixgood.com

Intrinsic
motivators
build energy
and creativity

Intrinsic
motivators
•connecting to
shared purpose
•engaging, mobilising and
calling to action
•motivational leadership
build energy
and creativity

Intrinsic
motivators
•connecting to
shared purpose
calling to action
build energy
and creativity create focus &
momentum for
delivery
Drivers
of extrinsic
motivation

Drivers
of extrinsic
motivation
create focus &
momentum for
delivery
Intrinsic
motivators
•connecting to
shared purpose
calling to action
build energy
and creativity
•System drivers &
incentives
•Payment by results
•Performance
management
•Measurement for
accountability

Internal
motivators
•connecting to
shared purpose
calling to action
build energy and
creativity
Drivers of
extrinsic
motivation
•System drivers &
incentives
•Performance
management
•Measurement for
accountability
create & focus
momentum for
delivery

An example
“Leaders and managers tasked with applying
integrated care ‘at scale and pace’ might … focus on
driving forward the organisational solution or
introduce various financial inducements in the hope
this will be more effective [than starting with
values-based shared purpose]. Such an approach
would be a mistake…
A values-driven approach should be a pre-requisite
to the successful adoption of integrated care.”
Goodwin, Nick. “Taking Integrated Care Forward: The Need for Shared Values.”
International Journal of Integrated Care 13, no. 2 (June 24, 2013).

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

The Change Model
www.changemodel.nhs.uk

Which components appeal to you and
why?

0
1
2
3
4
5
6
7
8
9
10
Our shared purpose
Spread of innovation
Improvement
methodology
Rigorous delivery
Transparent
measurement
System drivers
Engagement to
mobilise
Leadership for change
What's our prognosis for this
asthma pathway project?

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

Some questions
 Which group likely to have
higher spiritual energy
scores (clinicians/non
clinicians?)
 Nearer to CEO, higher or
lower energy scores?

@helenbevan@helenbevan #Quality2013
• 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

#SHCR @School4Radicals 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

“Matching Michigan” is a wonderful
example of the power of shared purpose
Perhaps the single most important influence on program response by individual
units—either in promoting or resisting change—was the extent of consensus and
coalition among the senior medical and nursing staff on individual ICUs….
Transforming or boosting of efforts was most likely to occur when those locally
charged with implementation were sincere in their beliefs about the value of the
program, were able to create transdisciplinary alliances, had local credibility
among peers, were prepared to tolerate debate but exercise firmness, and used
multiple tactics including role modelling, persuasion, sanctioning, reminders, and
constant feedback….
[Consultant says] ‘I think it’s been successful because it’s a unifying program, it’s
one of the few things that we’ve done that hasn’t been just a doctor thing, or just
a nurse thing, it’s involved the doctors and the nurses together.’
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3704826/

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

#SHCR @School4Radicals @SimonJGuilfoyle Police Inspector and systems thinker

Police
@SimonJGuilfoyle Police Inspector and systems thinker

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

Case study: Skin to skin
Jenny Clarke

Discussion
What is your experience as a change agent of:
 Building energy for change?
 Creating shared purpose?

 Wednesday 25th February
16:00-17:00 Tweet chat #SHCRchat
 Next Friday morning 27th February
module 4: Moving beyond the edge
 You can start the process of applying to
become a “certificated change agent”
Next opportunities for learning

The certification process
Take some actions to demonstrate your learning from
the school and become a “certificated change agent”.
If you complete the learning process you will:
• be recognised as a “certificated change agent” by the
school and NHS Improving Quality
• be awarded a virtual badge that you can used on
your email signature, personal website, etc.
• be invited to take part in one of our virtual
graduation ceremonies
• receive a certificate.

Call to action
 Reflect on how you can use both intrinsic and
extrinsic motivators in your practice as a
leader or agent of change.
 Seek to ignite energy for change in everyone
involved in your project.
 Build commitment to shared purpose in all
your change efforts.

Questions for reflection
1. How can I make the most of both intrinsic
and extrinsic aspects of change?
2. How can I build energy for the long haul?
3. How can I ensure shared purpose
throughout the change process?
4. What can I do tomorrow to accelerate
change?

SHCR 2015 module 4

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SHCR 2015 module 4