Leadership and change in health systems

Leadership & Change

in

Health Systems

ICHS 7

www.hpsa-africa.org

@hpsa_africa

www.slideshare.net/hpsa_africa

Introduction to Complex Health

Systems

Change:

where do things go wrong?

1.Weak design

Re-design process

• How are intervention effects likely to

ripple through system (consider the

BBs)?

• What re-design could

– offset negative effects?

– take advantage of positive synergies?

In strengthening design, need also to

consider:

Who to co-design with & how manage the

process?

How can implementation/change be

better managed?

Change:

where do things go wrong?

2.Weak change management

(implementation)

Causes of failure

A poor design and implementation plan

A weak enabling environment

A case of ignoring red tape and bottlenecks

A failure to learn

Failure

Kusek et al. 2013

Lack of senior management support; not listening to

critics; poor communication; lack of stakeholder

management plan; poor use of formal & informal

networks

Failure to admit

mistakes; aversion to

risk taking

Recognising complexity

• Complexity implies unpredictability

• Complex challenges require people and

organisations to change, often in

profound and fundamental ways

Change

does not happen by itself

has to be led and managed

occurs through people

and groups

Leadership:

Enabling others to face challenges

and achieve results under complex

conditions

Two key starting points for

leaders

• Personal reflection:

– hopes, aspirations, beliefs, interests, power

• Review of past experience:

– as influence over other agents

– as influence over implementation feasibility

Moving towards shared, inclusive,

collective, distributed

Leadership

Leadership for complexity

1. Shared sensemaking > collective

mindsets to support change

2. Creating connection > relationships

that enable change

3. Navigation > learning from innovation

& emergent strategies

Drath 2003

Commitment planning

• Describe the future & publicise the

change = the basis for commitment

• Commitment planning:– Who must be committed?

– What current commitment level?

– What changes need and how bring about?

(Barnes, 1995)

Planning for commitment changeKey agents No

commitment

(oppose)

Let it happen

(no active

support)

Help it happen

(need their

support)

Make it

happen

(willing to

lead)

CEO OX

Chairman

medical staff

committee

O X

Staff member

A

O X

Staff member

B

O X

Consultant C O X

Consultant D X O

Manager E O X

Change as political negotiation

• Select 4-5 most influential stakeholders who impact

on change & who you want to influence

– Identify potential senior champions and critics

• Think about how they will assess success of your

proposal & develop a plan to influence them so they

judge innovation a success

• Use positive support of these agents to influence

others

(Osborne and Brown, 2005)

Think about the use of

power

• Planned & imposed change may

encourage compliance without

commitment

• because it fails to provide spaces for the

new forms of sensemaking necessary to

support the intended changes

• Compliance: you do

something because

you have to

– Do just what is

required and no

more

– Purposively do the

wrong thing

• Commitment: you

want to do

something, you

believe in it

Power in health systems

From top to bottom

From bottom to

top

Sensemaking

• For organisational change to succeed it

must involve shifts in shared

assumptions and beliefs about how

things happen in the organisation and

how people act – changes in mindsets

of organisational agents

(Balogun 2006)

Leading sensemaking

• The way managers understand,

interpret, create and diffuse sense of

the information surrounding strategic

change

(Rouleau and Balogun 2007)

Pay attention to staff

• Ensure early involvement of staff in change

process

• Help staff face up to change

• Work through face to face communication

• Listen (and talk)

• Be positive in working to gain commitment to

change, enabling staff to see opportunities

not just threats

(Osborne and Brown, 2005)

Build commitment

Sensemaking:

• What visions?

• What messages?

• What ideas?

How build trust?

• What are agents’

natural attractors?

(values, behaviours

that people and the

organisation are

drawn towards)

• What simple rules?

(principles for

action)

Advice networks

Trust networks

Communications

networks

Visible: the formal organisation

Vision, Mission, Structure, Job

descriptions, Goals, Strategies,

Operating policies complicated

Invisible: the informal organisation

Power and influence patterns\Group

dynamics

Impulsiveness

Feelings

Interpersonal relations

Organisational culture

Individual needs

complex

Adapted from

Kusek et al.

2013

Tap into the

power of:

Building commitment

In a complex adaptive system

‘...organisational change is not

management induced. Instead,

organizational change is emergent

change laid down by choices made on the

front line’ (Weick 2009: 239)

Plan small wins

• Rather than being overwhelmed by the

difficulty of bringing about necessary

‘big changes’, break down the change

into a series of smaller steps or ‘small

wins’ that move towards that change

• Eat an elephant bite by bite

• A small win is a concrete, complete, implemented

outcome of moderate importance.

• By itself, one small win may seem unimportant.

• Once a small win has been accomplished, forces are set

in motion that favor another small win.

• When a solution is put in place, the next solvable problem

often becomes more visible.

• This occurs because new allies bring new solutions with

them and old opponents change their habits.

• Additional resources also flow toward winners, which

means that slightly larger wins can be attempted.

Karl Weick from “Small Wins: Redefining the Scale of Social

Problems,” American Psychologist, January 1984

Two types of small wins

1. Actions that can be implemented

quickly and successfully, and so build

support for change

2. The continuous application of a small

action targeting a key constraint to

change – and opening up opportunities

for longer-term and more radical

change

Type 1:

• Team building

workshop, getting

people to know each

other, planning new

initiative, generating

improved short -

term work

performance

Type 2:

• Breaking down

hierarchical barriers

by calling each other

by first name,

supporting

recognition of each

other as people,

encouraging

working together

and building trust

over the long-term

Benefits of small wins

• Reduces fear of change

• Clarifies direction

• Increases possibility of early successes,

which boost support for further action

• Helps us to feel good

And…

• Can’t pre-plan everything!

• Important to encourage learning through

doing

• In ways that build support and

commitment!

• Feedback loops matter

• Take risks & learn from mistakes

Learning through doing

• Apply the PDSA cycle to each small win

to provide basis for next cycle of action

P (lan)

D (o)

S (tudy)

A (ct)

Identify the problem

Design programmeinterventions

Implement and field test

Measure and give feedback

Have time for review, discussion, revision

Implement and field test the revised programme

Measure and give feedback, then repeat throughout implementation

Adaped

from Kusek

et al. 2013,

p.63

Five rules to increase

chances of success1. Build commitment to getting things done

2. Manage stakeholders: keep your champions

close but your critics closer

3. Work with the Informal networks in your

organisation

4. Manage processes

5. Learn as implement

Kusek et al., 2013

Five simple rules of large scale

Health System change

1. Engage individuals at all levels in

leading the change efforts

2. Establish feedback loops

3. Attend to history

4. Engage physicians

5. Involve patients and families

Best et al. 2013

Copyright

Funding

You are free:

To Share – to copy, distribute and transmit the work

To Remix – to adapt the work

Under the following conditions:

Attribution You must attribute the work in the manner

specified by the author or licensor (but not in any way that

suggests that they endorse you or your use of the work).

Non-commercial You may not use this work for commercial

purposes.

Share Alike If you alter, transform, or build upon this work,

you may distribute the resulting work but only under the same

or similar license to this one.

Other conditionsFor any reuse or distribution, you must make clear to

others the license terms of this work.

Nothing in this license impairs or restricts the authors’

moral rights.

Nothing in this license impairs or restricts the rights of

authors whose work is referenced in this document.

Cited works used in this document must be cited following

usual academic conventions.

Citation of this work must follow normal academic

conventions. Suggested citation:

Introduction to Complex Health Systems, Presentation

7. Copyright CHEPSAA (Consortium for Health Policy &

Systems Analysis in Africa) 2014, www.hpsa-africa.org

www.slideshare.net/hpsa_africa

This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no.

265482). The views expressed are not necessarily those of the EC.

The CHEPSAA partners

University of Dar Es SalaamInstitute of Development Studies

University of the WitwatersrandCentre for Health Policy

University of GhanaSchool of Public Health, Department of Health Policy, Planning and Management

University of LeedsNuffield Centre for International Health and Development

University of Nigeria Enugu Health Policy Research Group & the Department of Health Administration and Management

London School of Hygiene and Tropical MedicineHealth Economics and Systems Analysis Group, Depart of Global Health & Dev.

Great Lakes University of KisumuTropical Institute of Community Health and Development

Karolinska InstitutetHealth Systems and Policy Group, Department of Public Health Sciences

University of Cape TownHealth Policy and Systems Programme, Health Economics Unit

Swiss Tropical and Public Health InstituteHealth Systems Research Group

University of the Western CapeSchool of Public Health