Minicourse M8: IHI National Forumapp.ihi.org/FacultyDocuments/Events/Event-2760/Presentation-14397/... · Minicourse M8: IHI National Forum ... SlideShare •We are running a free

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#IHIForum #pirate @HelenBevan @KathrynPerera

Minicourse M8:IHI National Forum


Housekeeping and survival!

Breaks…

Fire alarms and exits…

Mobile technology

Toilet location…Security…

Network: IHIFORUMPassword: IHI28FORUM

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Be respectful

Constructive participation

Mutual learning

No stupid questions

Punctuality

Confidentiality and trust


We hope you were able to do the pre-work

Otherwise download the workbook from SlideShare http://www.slideshare.net/HorizonsCIC/minicourse-m8-prereading-and-workbook or give us your email address and we will email you a copy shortly

http://www.slideshare.net/HorizonsCIC/minicourse-m8-prereading-and-workbook

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What is your slogan for today?


Joining in today and beyond

• Please tweet using the hashtags #IHIForum and#Pirates

• Download these slides from the IHI website or from SlideShare

• We are running a free virtual school for change action, based on this curriculum

• Sign up yourself and/or create a learning group at http://theedge.nhsiq.nhs.uk/school/

http://theedge.nhsiq.nhs.uk/school/

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‘We need three kinds of people to transform healthcare;

patients, professionals and pirates. Be a rebel pirate!’

Lucien Engelen


We are helping to build a global community of change agents

YNEARLY10,000

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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


Source: http://www.slideshare.net/alwynlau/learning-theories-learner-needs

http://www.slideshare.net/alwynlau/learning-theories-learner-needs

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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


Source: @NHSChangeDay

http://www.citynet.com/

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People who are highly connected have twice as much power to

influence change as people with hierarchical power

Leandro Herrero

http://t.co/Du6zCbrDBC


“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://t.co/Du6zCbrDBC

http://www.thisiscolossal.com/

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Change is changing


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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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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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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Change is changing

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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Change is changing

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#IHIForum #pirate @HelenBevan @KathrynPerera21


Change is changing

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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


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

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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


The essential flaw of quality improvement methods

The essential flaw of [quality improvement methodology] is

that, when implemented, it tends to reinforce the mechanistic and

hierarchical models that are consistent with the mental maps

of most managers

Chris Argyris, Flawed advice and the management trap

Source of image: www.biblicalcreation.org.uk Read more at: http://www.slideshare.net/jurgenappelo/management-30-workout

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

http://www.biblicalcreation.org.uk/

http://www.slideshare.net/jurgenappelo/management-30-workout

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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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Programme Board




• The Clinical Director



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 Source: adapted by Helen Bevan

from Leandro Herrera




Programme Board




• The Project Manager



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 Source: adapted by Helen Bevan

from Leandro Herrera



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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


“I have some Key

Performance

Indicators

for you”

or

“I have a

dream”

Source: @RobertVarnam36

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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“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!


What happens to heretics/radicals/rebels/mavericks

in organisations?

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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

http://t.co/6CQtA4wUv1

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

need

William L McKnight


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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#IHIForum #pirate @HelenBevan @KathrynPereraSource : Lois Kelly www.foghound.com

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

Rebel

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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?

http://www.foghound.com/

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#IHIForum #pirate @HelenBevan @KathrynPereraSource : Lois Kelly www.rebelsatwork.com

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

Rebel

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Change starts with me

Source of image: jasonkeath.com

http://www.rebelsatwork.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


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

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Change agents need agency!

• The capacity of individuals to make their own choices and to take action in a given environment

• The social science debate between structure and agency - to what extent are a person's actions constrained by social systems? https://www.youtube.com/watch?v=d51dmIzqVGE

• Words that are connected to agency:

• Action

• Activity

• Effect

• Influence• Power• Intervention


Source: @NHSChangeDay

What is the issue here?

“permission” ? (externally generated)

or

agency? (internally generated)

https://www.youtube.com/watch?v=d51dmIzqVGE

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Individual versus 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


Building agency: some tactics

1. 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

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What is a

RCT?


Randomised Coffee Trial!

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Outcomes of randomised coffee trials

#SCHR #Quality2015 @HelenBevan @BoelGare @jackielyntonImage copyright: http://13c4.wordpress.com/2007/02/24/50-reasons-not-to-change/

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#SCHR #Quality2015 @HelenBevan @BoelGare @jackielynton


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

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

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#SCHR #Quality2015 @HelenBevan @BoelGare @jackielyntonSource: 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 twelfthcontact

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


“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.

—

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

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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”.

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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


Key tactic for change agents:Out-love everyone else

Source of image: Bradley Burgess

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

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Questions for reflection

1. What are the opportunities for me to build my perspectives and skills as an agent of change?

2. How can I build self efficacy as a change agent?

3. How do I move beyond skills and knowledge of change to live and be change?

4. Who can help and support me as a change agent?

5. What are the implications for the way I work?


Employee resistance is the most common reason executives cite for the

failure of big organizational-change

effortsScott Keller and Colin Price

(2011), Beyond Performance: How Great Organizations Build Ultimate

Competitive AdvantageSource of image: Businessconjunctions.com

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Leaders ask their staff to be ready for change, but do not engage enough in sensemaking........

Sensemaking is not done via marketing...or slogans but by emotional connection with employees

Ron Weil


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

‘‘

http://de.slideshare.net/haraldschirmer/strategies-for-corporate-change-the-new-role-of-hr-driving-social-adoption-and-change-in-the-enterprise

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“Stages of change” Transtheoretical model of behaviour change

Prochaska, DiClemente & Norcross (1992)

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• 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

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“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


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I am making plans & changing things

I do in preparation.










I have stopped smoking!



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I am continuing to not smoke.

I sometimes miss it – but I am still not

smoking











I am continuing to not smoke.

I sometimes miss it – but I am still not

smoking



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• 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

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• 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

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“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?

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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

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• 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


If your horse dies, get off itCherokee proverb

Source of image: fenwickgallery.co.uk

‘‘

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Harvard researchers put a gorilla image on this lung scan


Harvard researchers put a gorilla image on this lung scan

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What proportion of the radiologists who reviewed this scan actually saw the gorilla?

90%

25% 17%

80%

9%

60%


Question: what’s the most reliable way to predict the future effectiveness of a team?

Source: http://www.fastcompany.com/3049524/know-it-all/the-

science-behind-team-intelligence

http://www.fastcompany.com/3049524/know-it-all/the-science-behind-team-intelligence

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#IHIForum #pirate @HelenBevan @KathrynPereraSource of image: outskirtsbattledome.wikispaces.com

The easiest way to thrive as an outlier

...is to avoid being one

Seth Goodin


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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. ”

Source of image: orton.org

Nilofer Merchant


Models for action

Advocacy Act on behalf of others

Mobilising Means to articulate voice

Organising develops the capacity of people to act on their own behalf, developing their voice in

relationship with others

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“People who have ideas and drive are on every street, in every project, every workplace and school, waiting in the wings, ready to

be discovered. Someone has to reach them and recognize them. Someone has to ask them to step out, not to be consumers or

props or spectators but to be players in the unfolding drama of public life. And that someone is what we call a leader or

organiser.”

Michael Gecan, Going Public

Image via www.corganisers.org.uk


Who am I seeking to organise?

Where am I organising?

What am I organising for?

I AM ORGANISING (who?) _________________ TO (do what?) ______________________ THROUGH (how) ______________

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Creating calls to Action

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http://www.slideshare.net/amitkaps/fifth-elephant-2014-talk-crafting-visual-stories-with-data?sf3881865=1


Leadership is….

…accepting responsibility for enabling others to achieve shared purpose in the face of uncertainty

Marshall Ganz

Source of image: Tanveer Naseer

http://www.slideshare.net/amitkaps/fifth-elephant-2014-talk-crafting-visual-stories-with-data?sf3881865=1

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

action

values

emotion

Source: Marshall Ganz


Why Stories Matter

What we do Why we do it

Action

Head

Analysis

Strategy

Heart

Narrative

Motivation

Source of image: Dr. Christina Winsey AT Mind-Body Connection

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Story of Self

Source of image: swedenbourg-openlearning.org.uk


Talk to the person next to you

• Tell your story about why the change you are involved in now is so important to you

• Relate it to a personal experience

You have:

• 2 minutes to prepare your story

• 3 minutes each to tell your story

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#IHIForum #pirate @HelenBevan @KathrynPereraSource of image: www.tannerfriedman.com

Story of us


Vivid details

Source: Marshall Ganz

http://www.tannerfriedman.com/

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#IHIForum #pirate @HelenBevan @KathrynPereraSource of image: www.tannerfriedman.com

Story of NOW


“You did what you knew how to do and when you knew better you did better.”

Maya Angelou

Source of image: Vidya Sury

http://www.tannerfriedman.com/

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Evaluation / Revaluation

Source of image: bluepuzzle.org


Places for change agents to intervene in a system (leverage points) in increasing order of effectiveness

12. Constants, parameters, numbers11. The sizes of buffers and other stabilising stocks, relative to their flows10. The structure of material stocks and flows9. The lengths of delays, relative to the rate of system change8. The strength of negative feedback loops, relative to the impacts they are trying to correct against7. The gain around driving positive feedback loops6. The structure of information flows (who does and does not have access to information)5. The rules of the system (such as incentives, punishments, constraints)4. The power to add, change, evolve, or self-organise system structure3. The goals of the system2. The mindset or paradigm out of which the system — its goals, structure, rules, delays, parameters — arises1. The power to transcend paradigms

Source: Donella Meadows

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“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 Fitzgerald

Author, 1896-1940

#IHIForum #pirate @HelenBevan @KathrynPerera@HelenBevan

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“Absurdity and anti-absurdity are the two poles of creative energy.”

Karl Lagerfeld


Polarities in today’s minicourse

Old power & New power

List A & List B

Hierarchies & Networks

Transactions & Relationships

Lead with data & lead with emotions

At the edge & In the centre

On the inside & On the outside

Agency & Structure

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Polarities we regularly face as healthcare change agents

Centralise & Decentralise

Deliver operationally & Transform care

Standardise & Redesign

Short term & Long term

Reduce cost & Improve quality

Strong local teams & One organisation

Innovate & Control

Stability & Change


Polarity map concept

Source: Barry Johnson

+

–

New powerOld power

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Polarity map concept

Source: Barry Johnson

Centralise Decentralise

+

–

Centralise DecentraliseDecentraliseCentralise

Either-Or


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and

Action stepsActions to gain or maintain the positive results from focussing on this pole. Who? What? By when? Measures?

Early warningsMeasurable indicators that you can count that will let you know that you are getting into the downside of this pole.

Positive results of focus on this pole Positive results of focus on this pole

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

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

Deeper Fear from loss of balance

Greater Purpose Statement (GPS) - Why leverage this polarity?



Source: adapted from Barry Johnson

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and





Step one: agree the polarities you want to work on



and





Step two: fill in the positive and negative boxes


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and







Step three: complete the “greater purpose” and “deeper fear” statements


Q is a thriving, effective community of improvement leaders

The Q community fails to fulfil its potential

Example

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and





Step four: show the current and idea energy flows



and




Ideal energy flow: work towards the upside of both poles and you create

a virtuous circle leading to the higher purpose

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and







Typical energy flow


and






Step five: identify the “early warning signs” and build some “action steps”

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and











Step six: identify one big idea that has

emerged from your polarity mapping

activity


“Dotmocracy”

• One person from each group should stand by their sheet

• Each person has four dots

• We are voting for the “one big idea” that offers the best potential for change agents

• You can give all your dots to one idea or one dot each to four ideas

• You can’t vote for your own idea

• Switch the “standing” person half way so they can vote

Time available: 15 minutesSource of image: blog.strategyzer.com

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Reflection

One take-away learning

If we had more time…


Commitment

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Commitment

Be a rebel pirate

Find and organiseother rebel pirates

Take one concrete action in my community

Sign up, or sign up others,for the free virtual

School for Change Action

Source of image: Vidya Sury


Thank you