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...
What will you walk away with?
• Fundamental elements that define large scale change
• Overall framework for large scale ch...
Large Scale Change
A working definition

Large-scale change is the emergent process of moving
a large collection of indivi...
Large Scale Change –
What is it and What is it not?
Incremental Change
– Process improvement
– Relatively constant shape o...
Multiple of things
(lots of lots)
Summarising the key differences in the approach to
large scale change and “normal” change
Differences
Normal Change

Large...
Summarising the key similarities in the approach
large scale change and “normal” change
Similarities
Normal Change and LSC...
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
What happens when …
Structures only (no process or behaviour)
Process only (no structure or behaviour)
Behaviour only (no ...
Trajectories of Improvement

Ideal




Improvement

Structures/
Processesand
Behavior
Desired



Project Approach to
im...
Model of Large Scale Change

© NHS Institute for Innovation and Improvement, 2012
Large Scale Change
Tools

Thinking

•
•
•
•

• Structure, process and pattern
thinking
• Culture
• Complex Adaptive System...
Driver Diagrams
• Useful for group of leaders overseeing the LSC effort
• Take a high level improvement goal
— determine u...
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 ...
OR Team Training
Skill Building

Quality Improvement

Teamwork + Communication

Frontline Providers

Face to Face Sessions...
Specific Ideas to Test

Secondary Drivers /
Change Concepts
Primary Drivers

Winners

Fashion
magazines

Buying good
shoes...
Driver Diagram
• Key themes that will make a difference
• Mutually reinforcing changes in multiple areas
• Where does comm...
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 roug...
Turning an opportunity into action …
−Picture frames – what is in it you see, what is outside
you do not
−Provide shape an...
Our aspiration is to have a healthcare system with:
•
•
•
•
•
•

no needless death or disease
no needless pain
no unwanted...
How do we create change at scale?

Strategy
what?

Narrative
why?

Shared understanding leads to
Action

Source: Marshall ...
Building advanced improvement capability for BC
Building advanced improvement capability for BC
Clinical and Mobilisation
Clinical Mindsets for
Improvement
Effectiveness and Efficiency

The Mobilisation Mindsets for
Im...
Mindset Shift
From …. “current mindset”

To … “future mindset”

‒ Hierarchy – I don’t question those
above me
‒ Profession...
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
b...
Complex Adaptive Systems
Complex adaptive systems are composed
of many interdependent, heterogeneous
parts that self organize and co-evolve.

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

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

Pre...
Sense Making
So now what?

How do we lead in a complex system…
Acknowledge Unpredictability
• Allow design to be tailored to local cont...
So now what?

How do we lead in a complex system…
Facilitate Interdependencies
• Reinforce existing relationships when eff...
Power of Networks
Strong ties vs weak ties (social network theory)
When we spread change through strong ties …
– Interact ...
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...
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 f...
The new era requires a shift in thinking
From
Compliance

To
Commitment

States a minimum performance standard
that everyo...
Building Commitment and Connection
Key Players

No
Commitment

Let It Happen

Unit Clerks

X

Administration

X

Help It H...
The Value of Commitments
• We commit to specific actions that are measurable
– not vague promises
– not just outcomes

• M...
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 Movemen...
150 Lives – Lesson Learned
• Communicate frequently, carefully
• Positive affirmation works
• Local champions and regional...
Application
• What are you currently working on that could
use one of the large scale methods?
Driver Diagram
Framing
Mind...
Questions?
Marlies van Dijk
mvandijk@bcpsqc.ca
@tweetvandijk
Geoff Schierbeck
gschierbeck@bcpsqc.ca
@bcsurgquality
Meher S...
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
Translating Large-Scale Change into Everyday Improvement
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Translating Large-Scale Change into Everyday Improvement

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This presentation was delivered in sessions E7 and F7 of Quality Forum 2014 by:

Marlies van Dijk
Director, Clinical Improvement
BCPSQC

Geoff Schierbeck
Quality Leader, Surgery
BCPSQC

Meher Shergill
Quality Leader
BCPSQC

Published in: Health & Medicine
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Translating Large-Scale Change into Everyday Improvement

  1. 1. LEADING LARGE SCALE CHANGE Marlies van Dijk, Geoff Schierbeck & Meher Shergill Quality Forum 2014
  2. 2. 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
  3. 3. 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!
  4. 4. Large Scale Change A working definition Large-scale change is the emergent process of moving a large collection of individuals, groups and organisations to a fundamentally new future state. © NHS Institute for Innovation and Improvement, 2012
  5. 5. 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
  6. 6. Multiple of things (lots of lots)
  7. 7. Summarising the key differences in the approach to large scale change and “normal” change Differences Normal Change Large Scale Change Credible ambition Incredible ambition defined future state managing an emergent final state clear organisation scope agreed leaders throughout processes or systems or behaviours multiple organisations and partnerships distributed and changing leadership processes and systems and behaviours strong programme management programme management and social movement controlled through hierarchy managed through influencing and engagement compliance led* *Compliance can lead to commitment for some © NHS Institute for Innovation and Improvement, 2012 commitment led
  8. 8. Summarising the key similarities in the approach large scale change and “normal” change 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 © NHS Institute for Innovation and Improvement, 2012
  9. 9. What are some good examples of Large Scale Change? What makes it large scale? Your turn
  10. 10. Three Core Elements 1.Structure 2.Process 3.Patterns of Behaviour
  11. 11. What happens when … Structures only (no process or behaviour) Process only (no structure or behaviour) Behaviour only (no structure or process)
  12. 12. Trajectories of Improvement Ideal   Improvement Structures/ Processesand Behavior Desired  Project Approach to improvement Common  Approach to improvement - None Time © Charles Kilo, MD,GreenField Health
  13. 13. Model of Large Scale Change © NHS Institute for Innovation and Improvement, 2012
  14. 14. Large Scale Change Tools Thinking • • • • • Structure, process and pattern thinking • Culture • Complex Adaptive System Elements • Network Theory • • • • • • 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
  15. 15. 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
  16. 16. The “Steps” Source: NHS Institute for Innovation & Improvement
  17. 17. 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.
  18. 18. OR Team Training Skill Building Quality Improvement Teamwork + Communication Frontline Providers Face to Face Sessions Site level/ Regional events or Visits Site Visits Improve the Quality of Surgical Care in BC Distributed Leadership Data Physician Meeting Clinicians, Nurses, Administrators, BCMA, BCAS, CRNBC Local Risk Adjusted Model Support how to share data Multidisciplinary Partnerships Ministry + Board Influence/support Patient Perspective Cohesive Group – Tie in Efficiency Patient Voice (video) Patients on Planning Group Clinical Leadership Use clinical leaders to engage others Culture Survey Collaborative Sharing and Learning
  19. 19. Specific Ideas to Test Secondary Drivers / Change Concepts Primary Drivers Winners Fashion magazines Buying good shoes With friends Stretch Check out competition Aim / Outcome(s) HOW Looking Fashiona ble WHY HOW WHY HOW WHY Source: L. Couves, Improvement
  20. 20. Driver Diagram • Key themes that will make a difference • Mutually reinforcing changes in multiple areas • Where does commitment contribute
  21. 21. Aim: Quit smoking or other Primary Driver: Secondary Driver: Specific Ideas:
  22. 22. Framing
  23. 23. 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
  24. 24. 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
  25. 25. 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)
  26. 26. How do we create change at scale? Strategy what? Narrative why? Shared understanding leads to Action Source: Marshall Ganz and Helen Bevan
  27. 27. Building advanced improvement capability for BC
  28. 28. Building advanced improvement capability for BC
  29. 29. Clinical and Mobilisation Clinical Mindsets for Improvement Effectiveness and Efficiency The Mobilisation Mindsets for Improvement Energy for Change Metrics and Measurement Clinical Systems Improvement Reducing Variation Pathway Redesign Evidence Based Practice Imagination Engagement Moving Mobilising Calling to Action Creating the Future
  30. 30. Mindset Shift From …. “current mindset” To … “future 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 ‒ No infection is acceptable ‒ I can speak up when I have concerns ‒ Patients are equal partners ‒ We work in teams
  31. 31. Your Turn: Goal (area of work) From …. “current mindset” To … “future mindset”
  32. 32. 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
  33. 33. Complex Adaptive Systems
  34. 34. Complex adaptive systems are composed of many interdependent, heterogeneous parts that self organize and co-evolve. Unpredictable (Camazine, 2001; Kauffman, 1995; Allen & Varga, 2006)
  35. 35. 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)
  36. 36. Interdependencies Overarching term for relationships, connections, and interactions among parts of a complex system. Pre-Intervention Lindberg, C., & Clancy, T. R. (2010). Journal of Nursing Administration Post-Intervention
  37. 37. Sense Making
  38. 38. 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)
  39. 39. 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)
  40. 40. Power of Networks 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
  41. 41. Strong Ties – Group Exercise Advantages of Strong Ties Disadvantages of Strong Ties
  42. 42. 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
  43. 43. Weak Ties– Group Exercise Advantages of Weak Ties Disadvantages of Weak Ties
  44. 44. 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
  45. 45. The new era requires a shift in thinking From Compliance To Commitment States a minimum performance standard that everyone must achieve States a collective improvement goal that everyone can aspire to Uses hierarchy, systems and standard procedures for co-ordination and control Based on shared goals, values and sense of purpose for co-ordination and control Threat of penalties/sanctions/shame creates momentum for delivery Commitment to a common purpose creates energy for delivery Based on organisational accountability (“if I don't deliver this, I fail to meet my performance objectives”) Based on relational commitment (“If I don’t deliver this, I let the group or community and its purpose down”) Source: Helen Bevan
  46. 46. Building Commitment and Connection Key Players No Commitment Let It Happen Unit Clerks X Administration X Help It Happen Make It Happen QI O O X etc etc etc O XO X O 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)
  47. 47. 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
  48. 48. If we apply mindsets, values and social movement principles … Here is an example!
  49. 49. • • • • Identifying need for change Framing/Reframing the issue Engaging the community Attracting further interest
  50. 50. • Mindset shift: “from compliance to commitment” • Driver Diagram • Stakeholder analysis • Network theory • Social Movement theory • Strategy. Narrative. Action
  51. 51. 150 Lives – Lesson Learned • 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
  52. 52. 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
  53. 53. Questions? Marlies van Dijk mvandijk@bcpsqc.ca @tweetvandijk Geoff Schierbeck gschierbeck@bcpsqc.ca @bcsurgquality Meher Shergill mshergill@bcpsqc.ca
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