ihi national forum on quality and safety minicourse m10 ... · @helenbevan 1. able to join forces...
TRANSCRIPT
@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
@HelenBevan
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
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People who are highly connected have twice as much power to influence change as
people with hierarchical powerLeandro Herrero
http://t.co/Du6zCbrDBC
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“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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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
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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
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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
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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
@HelenBevan
@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