Translating Large-Scale Change into Everyday Improvement

LEADING LARGE SCALE CHANGE

Marlies van Dijk, Geoff Schierbeck & Meher Shergill Quality Forum 2014

At present, prevailing strategies [in healthcare] rely largely on outmoded theories of control and standardisation of work. More

modern and much more effective, theories seek to harness the imagination and

participation of the workforce in reinventing the system

Don Berwick, Former CEO, Institute for Healthcare Improvement

What will you walk away with?

• Fundamental elements that define large scale change

• Overall framework for large scale change

• Key practical tools and strategies to support you in your change efforts.

• Hopefully get you to try some of these when you get back home!

© NHS Institute for Innovation and Improvement, 2012

A working definition Large Scale Change

Large-scale change is the emergent process of moving a large collection of individuals, groups and

organisations to a fundamentally new future state.

Large Scale Change – What is it and What is it not?

Incremental Change – Process improvement – Relatively constant shape of a flowing river

Large-Scale Change

– Transformational, qualitatively different changes – Damming a river or altering its course

Source: P. Plsek. Creating Large Scale Change in Health Care. 2011

Multiple of things (lots of lots)

© NHS Institute for Innovation and Improvement, 2012

Summarising the key differences in the approach to large scale change and “normal” change

Normal Change Large Scale Change

Credible ambition

defined future state

clear organisation scope

agreed leaders throughout

processes or systems or behaviours

strong programme management

controlled through hierarchy

compliance led*

Incredible ambition

managing an emergent final state

multiple organisations and partnerships

distributed and changing leadership

processes and systems and behaviours

programme management and social movement

managed through influencing and engagement

commitment led

Differences

*Compliance can lead to commitment for some

© NHS Institute for Innovation and Improvement, 2012

Similarities

Normal Change and LSC

Working to an inspiring vision

Use best practice improvement tools

Require great leadership

Require effective team working

Urgency for delivery

Summarising the key similarities in the approach large scale change and “normal” change

What are some good examples of Large Scale Change?

What makes it large scale?

Your turn

Three Core Elements

1.Structure 2.Process 3.Patterns of Behaviour

Structures only (no process or behaviour)

Process only (no structure or behaviour)

Behaviour only (no structure or process)

What happens when …

Trajectories of Improvement

Time

Project Approach to improvement -

Common

Structures/ Processesand

Behavior Desired

© Charles Kilo, MD,GreenField Health

Impr

ovem

ent

Ideal

Approach to improvement - None

© NHS Institute for Innovation and Improvement, 2012

Model of Large Scale Change

Large Scale Change Tools

• Planning questions • Driver diagrams • 30/60/90 day cycles of change • Systems and stakeholders

analysis • Continuum of commitment

analysis • Framing and reframing • Mindsets • Transformational story telling • World Café • Measurement

Thinking

• Structure, process and pattern thinking

• Culture • Complex Adaptive System

Elements • Network Theory

Driver Diagrams

• Useful for group of leaders overseeing the LSC effort • Take a high level improvement goal

— determine underpinning goals (“drivers”) — determine projects/change ideas that will help you to

achieve • Visual of entire change process

– Inter-connections – Communication tool

• Framework for measurement • Update every 90 days

The “Steps”

Source: NHS Institute for Innovation & Improvement

What Changes Can We Make?

Primary Drivers System components which will contribute to

moving the primary outcome Secondary Drivers

Elements of the associated primary driver. They can be used to create projects or a change package that will affect the primary drivers.

Improve the Quality of

Surgical Care in BC

Skill Building

Face to Face Sessions

Site Visits

Distributed Leadership

Data

Multidisciplinary Partnerships

Patient Perspective

Clinical Leadership

Culture Survey

Teamwork + Communication

OR Team Training

Site level/ Regional events or Visits

Frontline Providers

Clinicians, Nurses, Administrators, BCMA, BCAS,

CRNBC

Local Risk Adjusted Model

Support how to share data

Patient Voice (video)

Physician Meeting

Quality Improvement

Cohesive Group – Tie in Efficiency Ministry + Board

Influence/support

Collaborative Sharing and Learning

Use clinical leaders to engage others

Patients on Planning Group

Looking Fashiona

ble

Fashion magazines

Stretch

With friends

HOW

Aim / Outcome(s)

Primary Drivers

Secondary Drivers / Change Concepts

Specific Ideas to Test

Winners

HOW HOW

WHY WHY WHY

Source: L. Couves, Improvement A i

Buying good shoes Check out

competition

Driver Diagram

• Key themes that will make a difference • Mutually reinforcing changes in multiple areas • Where does commitment contribute

Aim: Quit smoking or other Primary Driver: Secondary Driver: Specific Ideas:

Framing

What the leader cares about – and typically bases at least 80% of his or her message to others on – does not tap into roughly 80% of the workforces’ primary motivators for putting extra energy into the change programme. The inconvenient truth about change management, McKinsey Quarterly

Turning an opportunity into action … −Picture frames – what is in it you see, what is outside

you do not −Provide shape and structure for organising ideas and

arguments − ‘Hooks’ for pulling people in − ‘Springboards’ for mobilising support −Need to be authentic and connect with an

individual’s reality

Our aspiration is to have a healthcare system with: • no needless death or disease • no needless pain • no unwanted delay • no feelings of helplessness (for patients or staff) • no waste • and no inequality in service delivery

Adapted from: Don Berwick by Pursuing Perfection)

How do we create change at scale?

Source: Marshall Ganz and Helen Bevan

Shared understanding leads to Action

Narrative

why?

Strategy

what?

Building advanced improvement capability for BC

Building advanced improvement capability for BC

Clinical and Mobilisation Clinical Mindsets for Improvement Effectiveness and Efficiency Metrics and Measurement Clinical Systems Improvement Reducing Variation Pathway Redesign Evidence Based Practice

The Mobilisation Mindsets for Improvement Energy for Change Imagination Engagement Moving Mobilising Calling to Action Creating the Future

Mindset Shift From …. “current mindset” ‒ Hierarchy – I don’t question those

above me ‒ Professional silos ‒ Complications (e.g., infections) are

part of our business ‒ Partners must comply with what

we tell them to do

To … “future mindset” ‒ No infection is acceptable ‒ I can speak up when I have

concerns ‒ Patients are equal partners ‒ We work in teams

Your Turn: Goal (area of work)

From …. “current mindset”

To … “future mindset”

Why is change so hard in health care?

• Pilot projects generally do well

• Spreading throughout our system has proven to be difficulty

• Often attributed to variation at a local level

Complex Adaptive Systems

Complex adaptive systems are composed of many interdependent, heterogeneous parts that self organize and co-evolve.

Unpredictable

(Camazine, 2001; Kauffman, 1995; Allen & Varga, 2006)

Self-Organization

Self-organization is a process whereby local interactions give rise to patterns of organizing.

ADAPTIVE – RESILIENT – UNCERTAIN

(and difficult to manage)

H.J. Lanham et al., How complexity science can inform scale-up and spread in health care: Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)

Interdependencies Overarching term for relationships, connections, and interactions among parts of a complex system.

Pre-Intervention Post-Intervention

Lindberg, C., & Clancy, T. R. (2010). Journal of Nursing Administration

Sense Making

So now what? How do we lead in a complex system…

Acknowledge Unpredictability • Allow design to be tailored to local contexts • Emphasize discovery in each intervention setting Recognize Self-Organization • Develop “good enough” • Facilitate sense-making

H.J. Lanham et al., How complexity science can inform scale-up and spread in health care: Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)

So now what? How do we lead in a complex system…

Facilitate Interdependencies • Reinforce existing relationships when effective or foster new

ones • Encourage sense-making Encourage Experimentation • Encourage participants to ask questions, admit ignorance and

deal with paradox • Seek out different points of view

H.J. Lanham et al., How complexity science can inform scale-up and spread in health care: Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)

Strong ties vs weak ties (social network theory)

When we spread change through strong ties … – Interact with “people like us” with the same experiences,

beliefs and values – Change is peer to peer (e.g., nurse to nurse, GP to GP) – Influence is spread through people who are strongly

connected to each others, who like and generally respect each other

– It works because people are far more likely to be influenced to adopt new behaviors or ways of working from those they are most strongly tied

Source: Helen Bevan, 2011

Power of Networks

Strong Ties – Group Exercise

Advantages of Strong Ties

Disadvantages of Strong Ties

What About “Weak Ties”?

When we seek to spread change through weak ties: – We build bridges between groups and individuals

who are 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

– We mobilize all the resources in our system

Weak Ties– Group Exercise

Advantages of Weak Ties

Disadvantages of Weak Ties

We need BOTH strong and weak ties …

• Weak ties enable change at scale because they enable us to access more people with fewer barriers

• In situations with uncertainty, we gravitate to our strong tie relationships

– evidence shows that weak ties are much more important than strong ties

• More breakthroughs in innovation occur when we tap into weak ties

• The greatest opportunity we likely have for large scale improvement and change is through weak ties

• When framing your story – consider BOTH strong and weak ties

Source: Helen Bevan, 2011

From 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

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

To Commitment

States a collective improvement 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”)

The new era requires a shift in thinking

Source: Helen Bevan

Building Commitment and Connection

Key Players No Commitment

Let It Happen Help It Happen Make It Happen

Unit Clerks X O

Administration X O

QI X O

etc XO

etc X O

etc XO

Three Strategies: 1. Mobilizing narratives 2. Authentic Voices (e.g., Patients for Patient Safety Canada) 3. Hot-housing (e.g., energizing meetings and events out of usual

environment)

The Value of 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

• A definite “no” is always better than a wishy-washy “yes” or “maybe”

Source: NHS Institute for Innovation and Improvement, 2011

If we apply mindsets, values and social movement principles … Here is an example!

• Identifying need for change • Framing/Reframing the issue • Engaging the community • Attracting further interest

• Mindset shift: “from compliance to commitment”

• Driver Diagram • Stakeholder analysis • Network theory • Social Movement theory • Strategy. Narrative. Action

• Communicate frequently, carefully • Positive affirmation works • Local champions and regional connections

are key • Collective responsibility & willing

commitment can be an ally • Frequent feedback of results is effective in

stirring change • Gamification can be effect to spread best

practice

150 Lives – Lesson Learned

Application

• What are you currently working on that could use one of the large scale methods?

Driver Diagram Framing Mindset Exercise Weak ties/Strong ties

Questions?

Marlies van Dijk mvandijk@bcpsqc.ca

@tweetvandijk

Geoff Schierbeck gschierbeck@bcpsqc.ca

@bcsurgquality

Meher Shergill mshergill@bcpsqc.ca