ihi national forum on quality and safety minicourse m10 ... · @helenbevan 1. able to join forces...

@HelenBevan

@HelenBevan 2

1 = little experience, skill and/or confidence

10 = highly experienced, skilled & confident

What’s your starting point as a change agent?

@HelenBevan

We are helping to build a global community of change agents

YNEARLY

10,000More than

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The School has been formally evaluated by the Chartered Institute for Personnel & Development

• Change knowledge

• Sense of purpose & motivation to improve practice

• Ability to challenge the status quo

• Rocking the boat & staying in it

• Connecting with others to build support for change

Statistically significant positive effect on multiple dimensions of impact at both individual and

organisational level

@HelenBevan

Source: http://www.slideshare.net/alwynlau/learning-theories-learner-needs

@HelenBevan

The Fundamental Law of Conventional Conferences

The sum of the expertise of the people in the

audience is greater than the sum of expertise of

the people on stage

Dave Winer

““

Source of image: www.citynet.com

@HelenBevan

Source: @NHSChangeDay

@HelenBevan

People who are highly connected have twice as much power to influence change as

people with hierarchical powerLeandro Herrero

http://t.co/Du6zCbrDBC

@HelenBevan

“New truths begin as heresies” (Huxley, defending Darwin’s theory of natural selection)

Source of image: installation by the artist Adam Katzwww.thisiscolossal.com

Via @NeilPerkin

@HelenBevan

Change is changing

@HelenBevan

Kinthi Sturtevant, IBM

13th annual Change Management Conference June 2015

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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@HelenBevan

Source: Bromford P (2015), ”What’s the difference between a test and a pilot?”

Pilots are being replaced by rapid tests and prototypes

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@HelenBevan

Change is changing

@HelenBevan

How we communicate and connect

@HelenBevan15

@HelenBevan

Change is changing

@HelenBevan

Hierarchy AND network

@HelenBevan

Change is changing

@HelenBevan19

@HelenBevan

@HelenBevan

Change is changing

Change is moving tothe edge

@HelenBevan

An example from the British Cabinet Office

http://www.slideshare.net/Openpolicymaking/060715-change-cardscollated?next_slideshow=1

@HelenBevan

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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@HelenBevan

Jeremy Heimens TED talk “What new power looks like” https://www.youtube.com/watch?v=j-S03JfgHEA

old power new power

Currency

Held by a few

Pushed down

Commanded

Closed

Transaction

Current

Made by many

Pulled in

Shared

Open

Relationship

@HelenBevan

“I have some A&E Performance

Indicators

for you”

or

“I have a dream”

Source: @RobertVarnam

@HelenBevan

The Network Secrets of Great Change AgentsJulie Battilana &Tiziana Casciaro

As a change agent, my centrality in the informal network is more important than my position in the

formal hierarchy

@HelenBevan

The 3% rule for change

Just 3% of people in the organisation drive conversations with 90% of other people

Source: research by IC Kollectif

@HelenBevan

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 big change happen we need to connect networks of people who ‘want’ to contribute, including the influencers

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/systems affected by change

@HelenBevan

“I have some Key Performance

Indicators

for you”

or

“I have a dream”

Source: @RobertVarnam29

@HelenBevan

“Tomorrow’s management systems will need to value

diversity, dissent and divergence as highly as

conformance, consensus and cohesion.”

Gary Hamel

Image by neilperkin.typepad.com

is the new normal!

@HelenBevan

What happens to heretics/radicals/rebels/mavericks

in organisations?

@HelenBevan

@HelenBevan

We need rebels to lead change

•The principal champion of a change initiative, cause or action

•Rebels don’t wait for permission to lead, innovate, strategise

•They are responsible; they do what is right

•They name things that others don’t see yet

•They point to new horizons

•Without rebels, the storyline never changes

Source : @PeterVan http://t.co/6CQtA4wUv1

@HelenBevan

If you put fences around people, you get sheep. Give people the room they need

William L McKnight

@HelenBevan

We need to create more boat rockers!

• Rock the boat but manage to stay in it• Walk the fine line between difference and

fit, inside and outside• Conform AND rebel

• Capable of working with others to create success NOT a destructive troublemaker

Source: Debra Meyerson

@HelenBevanSource : Lois Kelly www.foghound.com

There’s a big difference between a rebel and a troublemaker

Rebel

36

@HelenBevan

Reflection

• What are your insights around “rebels” and “troublemakers”?

• What moves people from being “rebel” to “troublemaker”?

• How do we protect against this?

@HelenBevanSource : Lois Kelly www.rebelsatwork.com

There’s a big difference between a rebel and a troublemaker

Rebel

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@HelenBevan

Change starts with me

Source of image: jasonkeath.com

@HelenBevan

‘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

@HelenBevan

1. able to join forces with others to create action

2. able to achieve small wins which create a sense of hope, possibility and confidence

3. more likely to view obstacles as challenges to overcome

4. strong sense of agency belief that I am personally able to create the change

Four things we know about successful boat rockers

Source: adapted from Debra E Meyerson

CHANGE

me

BEGINS WITH

@HelenBevan

Change agents need AGENCY

• The capacity of individuals to make their own choices and to take action in a given environment

• Words that are connected to agency:

• Action

• Activity

• Effect

• Influence• Power• Choice

@HelenBevan

A big debate in social science

Structure versus Agency

@HelenBevan

Source: @NHSChangeDay

@HelenBevan

Source: @NHSChangeDay

@HelenBevan

Individual AND collective agency

Individual agency:People get more power and control in their own lives: patient 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

@HelenBevan

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

@HelenBevan

Building agency: some tactics1. Create change one small step at a time

2. Reframe your thinking:

• failed attempts are learning opportunities

• uncertainty becomes curiousity

3. Make change routine rather than an exceptional

activity

4. Get social support

5. Learn from the best

@HelenBevan

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

improvement

@HelenBevan

Avedis Donabedian

“Ultimately, the secret of quality is love.

…… If you have love, you can then work backward to monitor and improve the system”.

@HelenBevan

Project Aristotle: http://qz.com/625870/after-years-of-intensive-analysis-google-discovers-the-key-to-good-teamwork-is-being-nice/

After years of intensive analysis, Google discovers that the key to high performing, innovative teams is being nice

@HelenBevan

Incivility diminishes collaboration and performance in medical settings

• People who lack a sense of psychological safety—the feeling that the team is a trusting, respectful and safe place to take risks—shut down, often without realising it

• People are less likely to seek or accept feedback, to experiment, discuss errors or speak up

Christine Porath, Mastering Civility, a Manifesto for the Workplace

@HelenBevan

Key tactic for change agents:Out-love everyone else

Source of image: Bradley Burgess

@HelenBevan Source of image: sport-fitness-advisor.com

Any force that stops or slows movement

Resistance

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Why do organisational change programmes fail to achieve their objectives?

The majority of reported reasons are related to resistance to change

Source: McKinsey & Co

@HelenBevan Image copyright: http://13c4.wordpress.com/2007/02/24/50-reasons-not-to-change/

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@HelenBevan

‘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

)

@HelenBevan

Let’s think about “resistance” in old/new power terms

@HelenBevan

Let’s think about “resistance” in old/new power terms

• Change can be planned and managedthrough a rigorous process

• Resistance is a force to overcome

• Resistance prevents change

• Change agents must diagnose, manage and/or overcome resistance

• Resisters can otherwise be known as “laggards”, “blockers”, “in denial”

@HelenBevan

Resistance to change: the old power mindset

@HelenBevan

A transformation programme

Source: Sewell (2015) : Stop training our project managers to be process junkies

@HelenBevan

Old power mindset: the role of the change agent

“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 StonehouseThe change agent: the manager’s role in change

British Journal of Healthcare Management, Vol. 19, Iss. 9, 09 Sep 2013, pp 443 - 445

Source of image: Health IT Outcomes

@HelenBevan

• Change can be planned and managed through a rigorous process

• Resistance is a force to overcome

• Resistance prevents change

• Change agents must diagnose, manage and/or overcome resistance

• Resisters can otherwise be known as “laggards”, “blockers”, “in denial”

• Change in human systems is often emergent and hard to predict

• Change results from connections and interactions stimulating different viewpoints, shaping how people think about things

• Resistance is an inevitable consequence of a complex change process

• Resistance should be embraced and rolled with

Let’s think about “resistance” in old/new power terms

@HelenBevan

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

action

values

emotion

Source: Marshall Ganz

@HelenBevan

Resistant behaviour is a good indicator of missing relevance

Harald Schirmerhttp://de.slideshare.net/haraldschirmer/strategies-for-corporate-change-the-new-role-of-hr-driving-social-adoption-and-change-in-the-enterprise

Source of image: driverlayer.com

‘‘

@HelenBevan

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. Create 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

New power mindset: the role of the change agent

Source of image: rachtalks.pressprestige.com

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Mark Jaben on the science behind resistance

What NOT to do

But what we do do Instead of buyers (who “buy-in”), we need investors

What TO do

Engage people here

Engage people here

@HelenBevan

Data and facts don’t change our minds

http://www.newyorker.com/magazine/2017/02/27/why-facts-dont-change-our-minds

@HelenBevan

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

@HelenBevan

• 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

@HelenBevan

The best advice

Don’t assume motives

Assume a positive intent

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@HelenBevan

“Stages of change” Transtheoretical model of behaviour change

Prochaska, DiClemente & Norcross (1992)

@HelenBevan

• smoking cessation

• exercise adoption

• 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

@HelenBevan

• smoking cessation

• exercise adoption

• 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!

The model is mostly used around health-related behaviours

@HelenBevan

“Stages of change” Smoking

I am not aware my smoking is a

problem – I have no intention to quit

Prochaska, DiClemente & Norcross (1992)

@HelenBevan

“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

Prochaska, DiClemente & Norcross (1992)

@HelenBevan

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.

“Stages of change” Smoking

Prochaska, DiClemente & Norcross (1992)

@HelenBevan

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!

“Stages of change” Smoking

Prochaska, DiClemente & Norcross (1992)

@HelenBevan

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 am continuing to not smoke.

I sometimes miss it – but I am still not

smoking

“Stages of change” Smoking

Prochaska, DiClemente & Norcross (1992)

@HelenBevan

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 am continuing to not smoke.

I sometimes miss it – but I am still not

smoking

“Stages of change” Smoking

Prochaska, DiClemente & Norcross (1992)

@HelenBevan

Prochaska, DiClemente & Norcross (1992)

“Stages of change” Transtheoretical model of behaviour change

@HelenBevan

• Which stage do most change activities in health and care focus on?

• Which stage are most people actually at?

Some questions

@HelenBevan

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

@HelenBevan

• Designed for Stage 4 –ACTION!

• Mandated it through targets

• Despite compelling case for change – people often resisted it

• People did the task and missed the point

Example – WHO Surgical Safety Checklist

@HelenBevan

Source: Russ et al (2015) A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical Safety Checklist Across Hospitals in England: Lessons From the “Surgical Checklist Implementation Project” Ann Surg

Source of infographic here

@HelenBevan

“In hospitals without adequate resources and efficient systems, simply requiring the checklist to be used might not only fail to improve patient safety but might also introduce new risks for staff and patients. This is the exact opposite of what the

checklist was designed to achieve.”

@HelenBevan

• 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 when people resist?

@HelenBevan

The single biggest problem in communication is the illusion

that it has taken place

George Bernard Shaw

‘‘

@HelenBevan

• Listen and understand

• appreciate the starting point

• elaborate interests

• Roll with resistance

• Don’t argue against it

• Be curious and accepting

• Encourage elaboration of resistance• What makes it so hard?• What would help?

• Build meaning and conviction in the change

So what SHOULD we do?

See Motivational interviewing as a change management strategy

@HelenBevan

• 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

@HelenBevan

If your horse dies, get off itCherokee proverb

Source of image: fenwickgallery.co.uk

‘‘

@HelenBevan

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?

Thinking about your own situation

@HelenBevan 96

1 = little experience, skill and/or confidence

10 = highly experienced, skilled & confident

Where are you now as a change agent?

@HelenBevan

More for change agents

Session D10 or E10

“Head and heart in healthcare improvement”

@HelenBevan

Thank you