Rewriting the Rules: Enduring and Emerging Approaches to Change

#RTR2016

@HelenBevan #RTR2016

Rewriting the Rules: Enduring and

Emerging Approaches to Change

Helen Bevan

@HelenBevan

#RTR2016

#RTR2016


1. Identify major themes and trends in the global world of change that are starting to shake our world of healthcare improvement2. Consider the implications for our own practice as leaders and practitioners of change and improvement3. Test out some of the new change methods and approaches in an interactive way4. Consider the opportunities and implications of these for our own practice as leaders of healthcare improvement5. Take home a toolkit of new and additional approaches to supporting change to complement your existing healthcare improvement toolkit and make your improvement efforts more likely to succeed

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• Welcome and introductions; outline of the day• What’s our message for today?• What is happening in the wider world of change?• Why this is the era of the healthcare rebel• Coffee break in the form of a RCT (randomised coffee trial)• Change starts with me• Lunch• Rolling with resistance to change• Leading change in a complex world: managing polarities

(including coffee)• Sharing lessons learnt

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What is your slogan for today?

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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

http://www.thisiscolossal.com/

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What are the big themes for change in the world in which we now operate?

“Linear thinking does not prepare us for exponential times” Dion Hinchcliffe

http://www.slideshare.net/dhinchcliffe/vital-trends-in-digital-experience-and-transformation-in-2016-dreamforce-2016-by-dion-hinchcliffe

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Change is changing

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What approaches to change are needed in this environment?

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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

http://www.innovationexcellence.com/blog/2015/07/09/13th-annual-change-management-conference-highlights/?utm_source=hs_email&utm_medium=email&utm_content=20535245&_hsenc=p2ANqtz--W0963q5vEUgL7ecueQKfQ5nK0QPbROyo7BwHs10orC8Mhs-KVEWZbwEyxXf1c8rSQahhkhUXAPaEFtqlTzK5nEygUTw&_hsmi=20535245




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@HelenBevan #RTR2016Source: Bromford P (2015), ”What’s the difference between a test and a pilot?”

Pilots are being replaced by rapid tests and prototypes

http://www.bromfordlab.com/labblog/2015/7/22/tests-vs-pilots?utm_content=bufferc862c&utm_medium=social&utm_source=twitter.com&utm_campaign=buffer

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Acceleration of connectedness

Change is changing

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Digital skills are a critical capability for future leaders of improvement

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How does the NHS improvement community prefer to communicate?

Digital

Non-digital

ProactiveReactive

Source: RAND evaluation data from the Q community of improvement leaders

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How does the NHS improvement community prefer to communicate?

Digital

Non-digital

ProactiveReactive

Source: RAND evaluation data from the Q community of improvement leaders

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Hierarchical power is diminishing

Change is changing


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Change is changing


Hierarchical Power is diminishing

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The Challenges

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Change is changing

Change is moving to the edge


Hierarchical Power is diminishing

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An example from the Cabinet Office

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



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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 outcomesAylet Baron

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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

https://www.youtube.com/watch?v=j-S03JfgHEA

https://www.youtube.com/watch?v=j-S03JfgHEA

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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

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WHO makes change happen?

Source: adapted by Helen Bevan from Leandro Herrera

List A• The Transformation Programme

Board• The programme sponsor• The Programme Management

Office• The leads of the [insert number]

transformation work streams • The Clinical Director• The Team Leader /Unit Manager• The Change Facilitator

http://leandroherrero.com/people-who-perform-and-live-in-formal-org-land-and-people-who-have-makebreak-power-two-different-lists



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transformation work streams • The Clinical Director• The Team Leader /Unit Manager• The Change Facilitator

List B• The mavericks and rebels• The deviants (positive). Who do

things differently and succeed• The contrarians, because they can• The nonconformists who see things

through glasses no one else has• The hyper-connected. Good or bad,

they spread behaviours, role model at a scale, set mountains on fire and multiply anything they get their hands on

• The hyper-trusted. Multiple reasons, doesn’t matter which ones





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transformation work streams • The Project Manager• The Team Leader /Unit Manager• The Change Facilitator

List B• The mavericks and rebels• The deviants (positive). Who do

things differently and succeed• The contrarians, because they can• The nonconformists who see things

through glasses no one else has• The hyper-connected. Good or bad,

they spread behaviours, role model at a scale, set mountains on fire and multiply anything they get their hands on

• The hyper-trusted. Multiple reasons, doesn’t matter which ones


People who live and

perform in formal

organisation land and

people with the power

who have make or break

change are two different

lists (and we need BOTH)




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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 transformational change happen we need to connect networks

of people who ‘want’ to contribute

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

http://iedp.com/articles/vertical-leadership/?utm_source=Sign-Up.to&utm_medium=email&utm_campaign=13787-257163-Campaign+-+01/09/2016

http://iedp.com/articles/vertical-leadership/?utm_source=Sign-Up.to&utm_medium=email&utm_campaign=13787-257163-Campaign+-+01/09/2016

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Is your change process a cathedral or a bazaar?

http://www.unterstein.net/su/docs/CathBaz.pdf



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We have a lot of cathedrals

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

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Power in community“Power used to come largely through and from big institutions.Today power can and does come from connected individuals in community.When community invests in an idea, it co-owns its success.

Source of image: orton.org

Instead of trying to achieve scale all by ourselves, we have a new way to have scale. Scale can be in, with and through community.”

Nilofer Merchant

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“I have some Key Performance

Indicatorsfor you”

or

“I have a dream”

Source: @RobertVarnam

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“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!

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“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

“The single biggest mistake to avoid? Creating disruption at work. Focus on developing relationships, not disrupting and alienating people. Peter Vander Awera on learning from setbacks and failures

is the new normal!

##FabChangeDay

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What happens to heretics/radicals/rebels/mavericks

in organisations?

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@HelenBevan #RTR2016Source: Lois Kelly http://www.slideshare.net/Foghound/rocking-the-boat-without-falling-out

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We need rebels!•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

http://t.co/6CQtA4wUv1

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

needWilliam L McKnight

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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

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@HelenBevan #RTR2016Source : Lois Kelly www.foghound.com

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

Rebel

http://www.foghound.com/

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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?

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@HelenBevan #RTR2016Source : Lois Kelly www.rebelsatwork.com

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

Rebel

http://www.rebelsatwork.com/

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For our break, we will have a RCT

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• Randomised Coffee Trial!• Randomised Coffee Trial!

Randomised Coffee Trial!

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Outcomes of Randomised Coffee Trials

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@HelenBevan #RTR2016fabnhsstuff.net/fabchangeday/rct/ or google “Fab stuff RCT”

http://www.fabnhsstuff.net/fabchangeday/rct/

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Join in one of our national Randomised Coffee Trials

fabnhsstuff.net/fabchangeday/rct/ or google “Fab stuff RCT”

Mental health – for anyone interested in mental health issues Dementia – for anyone interested in dementia issues Staff wellbeing – for anyone interested in how staff are cared forPatient Safety – for anyone with an interest in ensuring patient safety across the health and social care systemHome First – looking at the issues around how people who have long-term health conditions receive care outside of hospitalLearning and Leading Together – for anyone interested in how patients and healthcare staff can work together in genuine partnershipMatExp – for anyone interested in improving maternity experience – women and families as well as professionals

http://www.fabnhsstuff.net/fabchangeday/rct/

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Sign up for action with the Fab Change Day app

app.fabchangeday.net

http://www.app.fabchangeday.net/

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Change starts with me

Source of image: jasonkeath.com

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‘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

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1. able to join forces with others to create action2. able to achieve small wins which create a sense

of hope, possibility and confidence3. More likely to view obstacles as challenges to

overcome4. strong sense of “self-efficacy”

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

meBEGINS WITH

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Self-efficacy

“If you think you can or think you

can't, you are right.”

Henry Ford

“The ability to act is tied to a belief that it is possible to do so”

Albert Bandura

There is a positive, significant relationship between the self-efficacy beliefs of a

change agent and her/his ability to facilitate change

and get good outcomes

Source of image:www.h3daily.com

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Source: @NHSChangeDay

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Source: @NHSChangeDay

What is the issue here?“permission” ?

(externally generated)or

Self efficacy ? (internally generated)

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Building self-efficacy: some tactics1. Create change one small step at a time2. Reframe your thinking:

• failed attempts are learning opportunities• uncertainty becomes curiousity

3. Make change routine rather than an exceptional activity4. Get social support5. Learn from the best

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@HelenBevan #RTR2016Image copyright: http://13c4.wordpress.com/2007/02/24/50-reasons-not-to-change/

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C http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively

http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively

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@HelenBevan #RTR2016Source: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively


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Make it a personal PERFORMANCE target.


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Research from the sales industry:How many NOs should we be seeking to get?

• 2% of sales are made on the first contact• 3% of sales are made on the second contact• 5% of sales are made on the third contact• 10% of sales are made on the fourth contact• 80% of sales are made on the fifth to twelfth contact

Source: http://www.slideshare.net/bryandaly/go-for-no

http://www.slideshare.net/bryandaly/go-for-no

http://www.slideshare.net/bryandaly/go-for-no

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“Papers that are more likely to contend against the status quo are more likely to find an opponent in the review system—and thus be rejected —but

those papers are also more likely to have an impact on people across the system, earning them

more citations when finally published”V. Calcagno et al., “Flows of research manuscripts among

scientific journals reveal hidden submission patterns,” Science, doi:10.1126/science.1227833, 2012.

—

#SHCR @HelenBevan #@HelenBevan

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


Avedis Donabedian

“Ultimately, the secret of quality is love.…… If you have love, you can then work backward to monitor and improve the system”.

#SHCR @HelenBevan #@HelenBevanProject 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

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




Key tactic :Out-love everyone else

Source of image: Bradley Burgess



“Stages of change” Transtheoretical model of behaviour change

Prochaska, DiClemente & Norcross (1992)


• 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!

The model is mostly used around health-related behaviours


“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


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

• Which stage are most people actually at?

Some questions


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

#SHCR @HelenBevan #IQTGOLD@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


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

http://www.nature.com/news/hospital-checklists-are-meant-to-save-lives-so-why-do-they-often-fail-1.18057?WT.mc_id=TWT_NatureNews


“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”.


• 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?


The single biggest problem in communication is the illusion that it has taken

place

George Bernard Shaw

‘‘


• 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

http://www.sustainableevolution.com/blog-1/2015/6/18/motivational-interviewing-as-a-change-management-strategy


• 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

Example from the worksheet

• 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


If your horse dies, get off itCherokee proverb

Source of image: fenwickgallery.co.uk

‘‘


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


“The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time and still retain the ability to function”F Scott FitzgeraldAuthor, 1896-1940


“Every conflict is an invitation to innovation.”

Mary Parker FollettSociologist, 1868-1933

#SHCR @HelenBevan #IQTGOLD@HelenBevan@HelenBevan


Polarities in today’s workshop

Old power AND New power List A AND List B

Hierarchies AND Networks Transactions AND Relationships

At the edge AND In the centre On the inside AND On the outside

Change methods AND Emergent change


Polarity map concept

Source: Barry Johnson

+

–New powerOld power



Polarity map concept

Source: Barry Johnson

Centralise Decentralise

+

–Centralise DecentraliseDecentraliseCentralise

Either-Or



Q is a thriving, effective community of improvement leaders

The Q community fails to fulfil its potential

Example


Positive results of focus on this left pole

Negative results of over-focus on the left pole to the neglect of the right pole

Negative results of over-focus on the right pole to the neglect of the left pole

Deeper Fear from lack of balance

Greater Purpose Statement - why balance this polarity?*

and

Adapted from the Polarity Management map, Polarity Associates

Polarity MapAction stepsHow will we gain or maintain the positive results from focusing on this left pole? What? Who? By When? Measures?

Action StepsHow will we gain or maintain the positive results from focusing on this right pole? What? Who? By When? Measures?

Early Warnings Measurable indicators (things you can count) that will let you know that you are getting into the downside of this left pole.

Early WarningsMeasurable indicators (things you can count) that will let you know that you are getting into the downside of this right pole.

Positive results of focus on this right pole


Healthcare

Rewriting the Rules: Enduring and Emerging Approaches to Change