how to be a great change agent - minicourse m10

@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents

Minicourse M10 How to Be a Great Change Agent

Monday 9th DecemberCrystal Ballroom, Salon D

8.30am to 4.00pm

Helen Bevan @HelenBevanRobert Varnam @RobertVarnamAndrew Hasler @AndrewHasler

IHI National Forum on Quality and Safety

#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

@helenbevan #1000LivesPlus

@helenbevan@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents

What happens to heretics/radicals/rebels/mavericks

in organisations?

“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

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

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@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents Source : Lois Kelly www.foghound.com

Sometimes people see us radicals as troublemakers

• 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?

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

Gandhi

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 @RobertVarnam #IHI25Forum #ChangeAgents Source: Foghound

Emerging themes in large scale change

Organisation Community

Power through hierarchy 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 Relationships

Dominantapproach

Emerging direction

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

@helenbevan

The Network Secrets of Great Change AgentsJulie 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

@rebelsatwork rebelsatwork.com

Across the world, the change agent movement is exploding!

@chagwwChangeagentsworldwide.com

@corprebelsCorporaterebelsunited.com

Source: @NHSChangeDay

www.changeday.nhs.uk/healthcare radicals

Five tactics for change agents

1. Start with myself2. Build alliances3. Work out what might help others to

change4. Create energy for change5. Don't be a martyr

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

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

@helenbevan@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents Source: Foghound

our commitment, in order to survive2. 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

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

"There’s only one corner of the universe you can be certain of

improving, and that’s your own self." Aldous Huxley

1. convictions and values-driven2. 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, self-efficacy and confidence

6. optimistic in the face of challenge see opportunities take account of obstacles

What do we know about successful boat rockers?

Three assumptions for change agents

1. Assume that everyone has a noble intention2. 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

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

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

1. Start with myself2. Build alliances3. Work out what might help others to change4. Create energy for change5. Don't be a martyr

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

@helenbevan #IQTGOLD@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents

What’s the financial incentive?

Who is performance managing?

What’s the project plan?

“I have some KPIsfor your”

“I have a dream”

Call to Action

What do you want to achieve?

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)

A good narrative motivates others by:

• achieving common purpose throughshared values and commitment

• uniting us around a collective vision ,focusing our energy towards a specific and real change

• creating contagious commitment

Values YEmotion

Action

Source: Marshall Ganz

But not all emotions are equal.........

inertiaurgency

anger apathy

solidarity isolation

you can make a difference

Self-doubt

hope fear

Action motivatorsAction inhibitors

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

• Time: 5 minutes

a skill to motivate others

to join you in action

Public narrative

Made in Dagenham

story ofselfcall to leadership

story ofnowstrategy & action

story ofusshared values &

experience

PURPOSE

COMMUNIT

URGENCY

experience

PURPOSE

COMMUNIT

URGENCY

Why I am called to do

this work

experience

PURPOSE

COMMUNIT

URGENCY

Our shared experience reveals our

shared values

experience

PURPOSE

COMMUNIT

URGENCY

Frame the urgency & hopefulness necessary to secure commitment & build momentum

towards our shared goal

experience

PURPOSE

COMMUNIT

URGENCY

Marshall Ganz

this work

shared values

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

Storytelling elements

o shared experience – shared valuesoemotionoploto vivid detailo 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?

Vivid details

The power of stories

How does this make you feel?

How did it achieve it?

What did it achieve?

experience

PURPOSE

COMMUNIT

URGENCY

this work

shared values

Yourturn

Working in trios

• Storyteller• Listener• Observer

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

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

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.

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?

experience

PURPOSE

COMMUNIT

URGENCY

Marshall Ganz

this work

shared values

“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

Case study: people with dementia and

antipsychotic drugs

“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”.

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

It doesn’t have to be that way!

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

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

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

Call to action for pharmacists

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

The largest simultaneous improvement

initiative in the history of the NHS

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 RolandStuart Sutton Helen Bevan

A 189,000 pledge mountain!

86 Source: @NHSChangeDay

“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

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

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

“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.

Example pledges

People took action all over the country

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

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.

3rd March 2014www.changeday.nhs.uk

1. Start with myself2. Build alliances3. Work out what might help others to change4. Create energy for change5. Don't be a martyr

“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!

“Stages of change” Smoking

I am not aware my smoking is a

problem – I have no 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 have stopped

smoking!

I am continuing to not smoke.

I sometimes miss it – but I am still not

smoking

I have stopped

smoking!

I am continuing to not smoke.

I sometimes miss it – but I am still not

smoking

“Stages of change” Transtheoretical model of behaviour change

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

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

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

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

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 #Staffschange@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents

What happens to large scale change efforts in reality?

In order of frequency:1. the effort effectively “runs out of energy” and

simply fades away2. the change hits a plateau at some level and no

longer attracts new supporters3. 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

Does fear motivate people to change?

burning platformversus

burning ambition@PeterFuda

Lessons for transformational change1. 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

TaskTalk 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 researchOrganisations with HIGH productive energy scored higher on:• overall performance - 14% higher• productivity – 17%• efficiency – 14%• customer satisfaction – 6%• customer loyalty – 12%

Download for free atwww.changemodel.nhs.uk

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:

@helenbevan

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

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?

• 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 profileSocial

Spiritual

PsychologicalPhysical

Intellectual

• 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 profileSocial

Spiritual

Intellectual

@helenbevan

Psychological

Physical

Spiritual

Social Intellectual

Energy for ChangeA 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.

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.

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.

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

Social

Spiritual

Intellectual

Team 1: what’s your assessment of their energy for change?

Social

Spiritual

Intellectual

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

Social

Spiritual

Intellectual

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

Where does team 1 go for help?Roadmap of resources for building energy for change

www.changemodel.nhs.uk

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?

@helenbevan @PowerNHS@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents

“You can’t impose anything on anyone and expect them

to be committed to it”Edgar Schein, Professor Emeritus

MIT Sloan School

@helenbevan #Staffschange@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents 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

“ 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 resourcesin controlling their actions Nilofer Merchant

@helenbevan @PowerNHS@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents

[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

A three word concept

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

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

Purpose

Obfuscation O-

@SimonJGuilfoyle Police Inspector and systems thinker

Police

Education

Healthcare

@helenbevan #Staffschange@HelenBevan @RobertVarnam #IHI25Forum #ChangeAgents 143

How do we create shared purpose?

Create a safe space

Look for commonalitie

s & understand differences

Create a statement of

purpose

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

....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 inspireDov Seidman

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

how to be a great change agent - minicourse m10

marshall ganz frame

weight control fruit

de facto purpose

shared experience reveals

psychological improvement goals

marshall ganz story

optimal energy profile

secure commitment

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