creating contagious commitment to change our journey so far

© NHS Institute for Innovation and Improvement, 2011

Creating contagious commitment to change

Our journey so far

Catherine HolmesNHS Institute for Innovation and Improvement


Today

• To share our learning around creating change at scale

• Tell you about our call to action and recruit you to join us

• Test out a new leadership practice• Tap into all of you as a collective resource• Enjoy ourselves


Building the mobilisation movement for quality and cost improvement

• What it might take to mobilise our staff, communities and people who use our services at scale to achieve cost and quality improvement

• Leadership actions we can take to shift power in the system and get the outcomes we seek

• Strategies for building change on a platform of commitment rather than just compliance

• How to create a compelling narrative for our quality and cost improvement efforts that builds a sense of urgency and a call for action that results in sustainable change


Three things that unite us

1. We are leaders who are called to serve those in need 2. We want to help secure the future of the NHS (and the

principles it stands for) by helping to deliver high quality care/support that makes best use of precious resources

3. We are prepared to invest in our own learning because we hope there might be some additional perspective, knowledge, skills and relationships that can help us in this quest


Dementia Action Alliance

Our goalBy 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 and that alternatives to

their prescription have been considered and a shared

decision has been agreed regarding their future care


Why a call to action?Which tradition of change?

Management of change

Organising and

mobilising


Which tradition of change?• Organisational behaviour• Leadership and management studies• Clinical/medical audit• Improvement “science”• Academic tradition(s) – 100 years



Which tradition of change?

• Community organising, campaigns and social movements

• Learning from popular, civic and faith-based mobilisation efforts.

• Academic tradition– 100 years

Organising and

mobilising



• Organisational behaviour• Leadership and

management studies• Clinical/medical audit• Improvement “science”• Academic tradition(s) –

100 years


• Learning from popular, civic and faith-based mobilisation efforts

• Academic tradition – 100 years


Organising and mobilising



• Organisational behaviour• Leadership and

management studies• Clinical/medical audit• Improvement “science”• Academic tradition(s) –

100 years


• Learning from popular, civic and faith-based mobilisation efforts.

• Academic tradition – 100 years


Organising and

mobilising


How an “organising” approach can contribute to our quality and cost goals

1. Build capacity for change and enable others2. Motivate and mobilise others to action by

connecting with emotions, through values3. Create a sense of “us” as the platform of a

movement for change4. Build commitment, not just compliance 5. Create focus by identifying the small number of

actions that people can commit to 6. Shift power in the system to people who deliver

services, people who use services, local communities


“Often change need not be cajoled or coerced. Instead it can be unleashed.”

Kelman, S. (2005) Unleashing Change. A study of organizational renewal in government, Brookings Institution

Press; Washington, D.C


Focus: energy for change

• imagination• engagement• moving• mobilising• calling to action• creating the

future

The ‘clinical system’

mindset for improvement

Focus: effectiveness and efficiency

• metrics and measurement;

• clinical systems improvement,

• reducing variation, • pathway redesign, • evidence based

practice

How do we create improvement at scale?The

‘mobilisation’ mindset for

improvement

NHS Institute for Innovation and Improvement 2010Source: NHS Institute for Innovation and Improvement (2009) The Power of One, The Power of Many


Deficit based

what is wrong?-

solving problems-

identifying development and improvement needs

-gaps and deficiencies to

be filled

Asset based

what is right that we can build on?

-exploiting existing assets

and resources-

“positive deviance”-

amplifying what works

Approaches to change


FromCompliance

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

Based on organisational accountability (“if I don't deliver this, I fail to meet my performance objectives”)

To

CommitmentStates 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

Based on relational commitment (“If I don’t deliver this, I let the group or community and its purpose down”)

From the old world to the new world

Source: Helen Bevan


Five leadership messages to consider1. In our new world, we need levers for commitment,

not just compliance2. We build commitment to actions, not just outcomes3. Mobilising for change isn't enough; we need to

organise4. We seek to turn the resources we have into the

power we need to win the change we want5. As quality and cost improvement is here for the long

haul, we need to manage our own energies and those of the people around us


Challenge no 1

There is a lot of activity and energy for change.......

Unless that energy is translated into appropriate action that improves outcomes, it counts for nothing

How do we provide a focus and an energy that moves everyone in the same direction?


How did the great social movement leaders change the world?

Source: Marshall Ganz

Shared understanding leads toAction

Narrativewhy?

Strategywhat?


On your tables-Think of a social movement you have been involved with –

Why did you take part?what were its features?What actions were you required to take?


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

action

values

emotion



OUR GOALS AND OUR PROGRESS


Dementia Action Alliance

Our goalBy 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 and that alternatives to

their prescription have been considered and a shared

decision has been agreed regarding their future care


Our strategy

• To launch a nationwide “call to action”• To work in partnership with the Dementia

Action Alliance and other networks and organisations that can make a contribution

• To engage everyone who can play a part in helping to achieve our goal

• To move beyond mobilising to organising to make this happen


What did we need to agree?

• Who we are calling to action• What actions we want them to take• The sources of support and resources that will

be made available to help them in their actions


Priority groups to call to action

• The clinical decision makers who prescribe and review therapeutic interventions

• Those who we want to shift power to (e.g., people with dementia and their carers)

• Those who can give voice and advocacy to people with dementia and their carers

• Those with authority who can promote and ensure best practice


Eight groups to call to action

• People with dementia and their carers• Leaders of care homes• GPs and primary care teams• Psychiatrists and mental health teams• Pharmacists • Hospital doctors and multi disciplinary teams• Commissioners of health and social care• Medical Directors and Nurse Directors of acute

and mental health trusts/providers


Making commitments

• We commit to specific actions that are measurable, • not vague promises• not just outcomes

• Make commitments as simple as possible • “one specific action”

• We want to hold people to account to the things that they commit to

• When we do it effectively, commitment is much more effective than compliance


Establish a clear dialogue and agree joint working practices for reviews with all prescribing partners

I (we) commit to:reviewing the

people under my care to identify those who are

prescribed antipsychotic

medication and working in

partnership with my prescribing

and other healthcare

colleagues to review

each individual by 31st March 2012

Take on best practice guidelines for the prescribing of antipsychotic medication and alternative interventions or people with dementia. Provide support and sign-posting to alternative resources for people with dementia and their carers

Community pharmacists:Query every prescription for an antipsychotic for people aged 65 years and over and search for, and audit, all people 65 years and over who have received antipsychotic medication in the last 3 months

Hospital pharmacists:Query every prescription for an antipsychotic for people aged 65 years and over and ensure that discharge information is up to date regarding the actions GPs should take (in line with NICE guidelines)

CALLTO ACTION FOR PHARMACISTS

What specific action? What are the main themes for action?


Telling your own story and securing commitment


How did the great social movement leaders change the world?


Shared understanding leads toAction

Narrativewhy?

Strategywhat?


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

action

values

emotion



And not all emotions are equal.........

inertiaurgency

anger apathy

solidarity isolation

you can make a difference

Self-doubt

hope fearO

verc

ome

Action motivatorsAction inhibitors


What do we need to do?

1. Tell a story



1. Tell a story2. Make it personal



1. Tell a story2. Make it personal3. Be authentic



1. Tell a story2. Make it personal3. Be authentic4. Create a sense of “us” (and be clear who the

“us” is)


What do we need to do?(narrative)• Tell a story• Make it personal• Be authentic• Create a sense of “us” (and be clear who the

“us” is)• Build in a call for urgent action

• Identify the intolerable condition• Outline the nightmare if we fail to act.• Offer hope and • Call people to join us in taking a specific action


Ghandi

While you listen please consider the following:• What values did you hear?• What was the nightmare situation he

described?• How did he offer hope?• What choices did he offer?• How did he build a sense of us?• What action did he ask people to take ?


Debrief


“How wonderful it is that nobody need wait a single moment before starting to

improve the world”

Anne Frank, Diary of a Young Girl, 1945


How do we create a sense of “us” to build a movement for change in health and healthcare?


strong tiesversus

weak ties


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 a strong tie strategy

Advantages Limitations


Strong and weak tiesWhen 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

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

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 potentially help achieve our goals


Why we need to build weak ties AS WELL as strong ties• Weak ties are typically a more effective starting point for

influence at scale because they enable us to access large portions of the population, with fewer barriers than strong ties

• 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.

• Our best new ideas about how to deliver more effectively with less - and the most breakthrough innovations of the NHS - will come when we tap into our weak ties

• History suggests that a weak ties strategy will probably give us the best chance to deliver the scale of improvements we seek in quality and cost in a challenging timescale


leadership messages for you to consider

1. The traditional “strong ties” model of spreading change in the NHS offers both strengths and limitations

2. The “weak ties” philosophy underpinning many successful social movements helps us to build common ground between disparate groups and individuals

3. Our best new ideas about how to deliver more effectively with less - and the most breakthrough innovations of the NHS - will come when we tap into our weak ties

4. When, as leaders, we call people to action, we should include diagnostic, prognostic and motivational elements in the framing of the message


Three components of “core framing”• Diagnostic framing - aims to identify the problem

that the movement will address and attribute the problem to a specific source or sources-

• Prognostic framing - relates to the creation of a plan of attack and clear strategies for carrying out the plan

• Motivational framing - typically stresses urgency and an overall duty of/ call for action that connects with the motivational and emotional drivers of the audience.


Diagnostic framing• In the UK 180,000 people a year are treated with

antipsychotic medication• Of those only 36,000 receive any benefit from this

treatment• The resulting 144,000 people receive the medication

needlessly as staff and carers are often unaware of alternative therapies

• As a result over 1600 people experience an adverse cerebral event and 1800 people die needlessly because of taking inappropriately prescribed anti-psychotic medication.

• Reducing anti-psychotic medication in two thirds of people with Dementia would result in a potential saving of £55 Million


Prognostic framing • To deliver on the national ambition of reducing anti-psychotic

prescribing by two thirds by Nov 2011 we all have a part to play.• Maximise the opportunities of the Dementia Declaration to bring local

organisations together to discuss improvement across local communities and ensure that the voice of the person drives service improvement

• We need every PCT and local authority to outline plans to audit anti-psychotic prescribing practice and adopt best practice

• We need every GP to undertake a prescribing and treatment review of every patient with Dementia and agree shared decisions regarding treatment options.

• We need every care home team to review each of their residents and in partnership with them consider use of alternative therapies.

• We need every acute Trust to provide training in dementia to ensure that people with dementia spend as less time as possible in acute care and receive appropriate medication .


Motivational framingI’m not dying with dementia, I’m living with it. I don’t want to be left on the shelf”.• I want you to count up to 7…….• Every 7 seconds someone is diagnosed with dementia and

currently many face a bleak life sentence.• Every day 5 people die and 4 people experience significant

harm as a result of taking medication they may not need.• We have the opportunity to give a voice back to 144,000 people

with Dementia-by stopping unnecessary antipsychotic prescribing and agreeing with them their options for treatment and support

• And in doing so have the power to save 1800 lives and prevent over 1600 adverse cerebral events

• The task ahead is within our grasp-it is the equivalent of every GP reviewing just 9 people a year -less than 1 per month.


Relationships: securing Commitment


Our organising principle

• We work on the principle that we need commitment to succeed

• And that we must invest significant time and intention in building relationships that generate commitment

• Commitment to each other (“us”) and commitment to our goals


So how do we develop commitment..... through relationships

• Relationships are rooted in shared values and

we learn our shared values through shared

stories, understanding the choice points for

people and asking “why”


Relationships develop through exchanges

• Relationships grow out of exchanges of interests and resources

• The key is identifying these interests and resources

• We are not simply looking for someone to meet our need we are looking to build leaders to join us

• Growing our constituency


INTERESTS

RESOURCES

RESOURCES

INTERESTS

COMMMITMENT


Commitment

• An exchange between people becomes a relationship when we give a portion of our most valuable resource…….time

• A commitment of time gives the relationship a future and, therefore, a past

• And as we learn and grow so does the relationship offering possibilities for enriched exchanges


The more we share

• Over time we nurture and learn • We continue to grow and build our

relationships• We develop new relationships that offer

greater resources and possibilities• Sometimes simply knowing that we are

not fighting alone give us the energy to carry on to keep committing to our goal


So to recap

• Relationships are rooted in shared values• Relationships grow out of exchanges of

interests and resources• Relationships are created by commitment


Building intentional relationships

• One to one and the 5 do’s• Attention• Interest• Exploration• Exchange• Commitment


Attention

• Don’t be vague be upfront• Why are you meeting this person? • Take time to understand their values by sharing

yours• Do you have a common goal? • Be open about your agenda


Interests

• What is your goal?• What do you want to achieve from the meeting?• Have you planned this one to one address your

call to action interests?


Exploration

• A large proportion of your one to one should be about exploring to learn the other person’s values, interests and resources

• What resources do you have that they could potentially need or use?

• This is a two way process


Exchange

• We learn to share• We exchange our resources information and

insight .....which creates a foundation to build on to

develop your relationship and explore further your shared commitments


Commitment

• Good one to ones end with a commitment• Meeting again• Make it real, not it was nice to see you...

see you again• Can we make a pledge


Intention prevents failure

• Do plan this meeting in• Don’t be unclear about purpose and time• Plan to listen• Don’t try to persuade rather than listen• Follow the 5 do’s• Don’t chit chat about private interests• Share experiences and motivations• Don’t skip bits to get to the point• Share a vision of interests and hope• Don’t miss the opportunity to discuss change• Be clear about next steps• Don’t end without a clear plan


Group work 20 minutes • Break into pairs and practice a one to one• Go deep and ask some probing questions• After 10 minutes switch over• Listen out carefully and make note when you hear

• Your common values• Your shared interests• Your skills and resources

• Did you secure a commitment?


Debrief 5 Minutes

• Did it work? What made it work?• What kind of reaction did you get from your

counterparts?• What did you learn about the values you shared?• About common interests?• About the resources each of you bring?

• What did you find particularly challenging?


Gladys Wilson and Naomi Feil


Make a commitment towards this call to action• Join the Call to Action platform• Share your resources• Build your weak ties• Commit to having a 121 in next 14 days and

email me and tell me how it went.

creating contagious commitment to change our journey so far

Documents

improvement nhs institute

mobilising nhs institute

tradition of change

quest nhs institute

future care nhs institute

cost improvement efforts

building change

catherine holmesnhs