Leading large scale change for integrated care
Dr Robert Varnam PhD MRCGP
Head of general practice development, NHS Englan...
Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Seque...
Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Seque...
The story so far
Structure + process = outcome
Structures
Infrastructure
ProcessesBehaviours
The story so far
We have often focused on
structures & provider-led change
… and ended up with integration of providers
(m...
So what are we dealing with?
Improvement or transformation?
Improvement Transformation
Doing things
better /
differently
Doing
better / different
things
What is „large scale‟ change?
Depth
of change vis-à-vis
current ways of thinking
and doing; a.k.a
cognitive-behavioural
or...
Large scale change usually fails
Source: McKinsey Performance Transformation Survey, 3000 respondents to global, multi-ind...
Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Seque...
Levers for change
What happens ...
Levers for change
What happens ...
Levers for change
What happens ...
Levers for change
What happens ...
Levers for change
What happens ...
Levers for change
Very few of our „wicked‟ problems will be addressed by believing the health and
care system is a machine...
Complex Complicated
Chaotic Simple
Emergent practice Good practice
Best practiceNovel practice
Snowden D & Benford RD. The...
www.youtube.com/watch?v=ctMty7av0jc
Coordinated, behaviour – thousands of birds moving ‘as one’ – with no external control...
Leading in complexity
 A small number of simple rules
 Acting within each unit
 A few well-tested external influences &...
Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Seque...
A different paradigm
What’s the
financial incentive?
Who is
performance
managing?
What’s the
project plan?
“I have some KPIs
for your”
or
“I have a dream”
“You can’t impose anything
on anyone and expect them
to be committed to it”
Edgar Schein
Professor Emeritus, MIT Sloan Sch...
Drivers
of extrinsic
motivation
 regulation
 payment & incentive
systems
 performance
management
 measurement for
acco...
build energy and
creativity
Internal
motivators
 connecting to
 shared purpose
 engaging, mobilising and
calling to act...
How do we create shared purpose?
Identify shared
values
Create a safe
space
Create a
vision for the
future
Describe why
th...
[Shared] purpose goes way deeper than
vision and mission; it goes right into your gut
and taps some part of your primal se...
Using shared purpose
The „why‟ of
your change
A gravitational
force for drivers
The fuel that
won‟t run out
A uniting forc...
Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Seque...
Complex Complicated
Chaotic Simple
Emergent practice Good practice
Best practiceNovel practice
Snowden D & Benford RD. The...
Sequencing in large scale change
Identifying
need for
change
Framing/
reframing
the issues
Engaging/
connecting
others
Mak...
Large Scale Change
The emergent process of mobilising a large collection of individuals, groups
and organisations toward a...
Leading large scale change for integrated care
 The story so far
 Change in complexity
 Creating shared purpose
 Seque...
Conclusions from the evidence
Successful integration requires:
• shared purpose & collaborative
behaviours, more than new ...
Conclusions from the evidence
“Leaders and managers tasked with applying integrated care „at scale
and pace‟ might … focus...
Conclusions from the evidence
• Eventually, successful
commissioners have to adopt
different approaches:
• see the whole s...
Top tips (NHS Academy for Large Scale Change)
1. Moving towards a new vision that is better and fundamentally different fr...
Top tips (NHS Academy for Large Scale Change)
1. Continually refreshing the story and attracting new, active supporters
2....
bit.ly/1fBri9W
bit.ly/1fUNUkl
slidesha.re/1pSSbJh
enquiries@nhsiq.nhs.net @robertvarnam
2013 03-03 - large scale change for integrated care - r varnam (slideshare)
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  • For a more detailed introduction to the Cynefin framework, this video is excellent: https://www.youtube.com/watch?v=N7oz366X0-8
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  • Acknowledgements & link to IQ CCGD
  • SIMPLE – direct & obvious cause & effect
  • SIMPLE (if you know it) - ?COMPLICATED – long chain of cause & effect
  • COMPLICATED – it might take a while, but it’s still knowable. And reproducible.
  • How knowable is it? How predictable? How reproducible?What if you did it repeatedly?
  • How knowable is it? How predictable? How reproducible?What if you did it repeatedly?
  • How knowable is it? How predictable? How reproducible?What if you did it repeatedly?
  • The Cynefin (“kin-EV-in”) Framework. Useful for making sense of the ‘space’ you’re in and choosing a decision approach accordingly. www.youtube.com/watch?v=N7oz366X0-8 The framework was developed by Dave Snowdenden while working at IBM. Simple, in which the relationship between cause and effect is obvious to all, the approach is to Sense - Categorise - Respond and we can apply best practice.Complicated – good practice .. several options exist, experts should be allowed to choose from among them.Complex, - low control approach .. ‘agents modify the system’ (Dave Snowdenden). Probe-Sense-Respond = conduct experiments: “safe fail experiments, not fail-safe design” (Snowdenden). You can move towards order, but it emerges over time.Chaotic, Can be entered intentionally = innovation. If accidental = you need to “act” to stabilise situation quickly, using novel practice. Disorder = state of not knowing what type of causality exists, in which state people will revert to their own comfort zone in making a decisionthe boundary between simple and chaotic is seen as a catastrophic one: complacency leads to failure.
  • VIDEO – flocking birds
  • Examples of Social Movements: people doing something for a cause …The early psychosis declaration: Under the banner of IRIS a small group of people from around the UK gathered in Cheltenham in 2001 to discuss how they might generate a consensus on how services could be improved for young people with psychosis and their families. From those initial ideas the launch of the National Institute for Mental Health in England provided an ideal platform for further development.  40 people (service users, family members, and expert practitioners) met with representatives of the World Health Organisation (WHO), IRIS and Rethink to agree standards of care that those developing early psychosis and their families should expect. The IRA Hbloock/Armagh: IRA leaders detained in prison went on a dirty protest and refused to eat – Bobbly Sands was elected to the UK parliament whilst in prison and not allowed to take up his seat and died in prison. Greenpeace: surely everyone knows something about Greenpeace?100k lives campaign: in the USA from IHI, participating organizations agreed to provide monthly mortality statistics and adopt at least one of six interventions. These interventions included dispatching rapid response teams at the first sign of patient decline, following rigorous protocols to prevent infections caused by surgery, central venous catheters, and ventilators, giving heart attack patients recommended medications when they enter and leave the hospital, and checking to make sure all medications taken by a patient are appropriate. The 5 Million Lives Campaign calls for six additional interventions, including guidance on best practices to prevent pressure ulcers and to reduce Methicillin-Resistant Staphylococcus aureus (MRSA) infectionMarathon runners: City marathons for charity as well as elite athletes started in London on the 80s and have grown and spread all over the worldSuffragettesCND: peace marchers and peace camps against nuclear war British Heart Foundation – could have any number of charities
  • Large scale action - Not requiring large leadership team or compliance frameworkDefinition used in “The Power of One, the Power of Many” = a voluntary collective of individuals committed to promoting or resisting change through co-ordinated activity.
  • Connection is made with individuals by connecting with their values
  • why shared purpose is a critical issue for NHS transformationhow shared purpose is different to organisational purposehow shared purpose underpins all other elements of the NHS Change Model how to build shared purpose
  • Lots of evidence from around the world about how commissioners actually do their job. It’s worth reading.This is just one example, with key lessons here.This recent summary of several in-depth case studies shows that successful commissioners have to break out of some of the traditional moulds.
  • Lots of evidence from around the world about how commissioners actually do their job. It’s worth reading.This is just one example, with key lessons here.This recent summary of several in-depth case studies shows that successful commissioners have to break out of some of the traditional moulds.
  • 2013 03-03 - large scale change for integrated care - r varnam (slideshare)

    1. 1. Leading large scale change for integrated care Dr Robert Varnam PhD MRCGP Head of general practice development, NHS England Clinical lead for CCG & primary care delivery, NHS Improving Quality GP, Robert Darbishire Practice, Manchester @robertvarnam robert.varnam@nhs.net
    2. 2. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
    3. 3. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
    4. 4. The story so far
    5. 5. Structure + process = outcome
    6. 6. Structures Infrastructure ProcessesBehaviours
    7. 7. The story so far We have often focused on structures & provider-led change … and ended up with integration of providers (more than care) … made more improvements than transformations ... and found progress hard to sustain … which was entirely predictable
    8. 8. So what are we dealing with?
    9. 9. Improvement or transformation? Improvement Transformation Doing things better / differently Doing better / different things
    10. 10. What is „large scale‟ change? Depth of change vis-à-vis current ways of thinking and doing; a.k.a cognitive-behavioural or paradigm shift Pervasiveness of change; does it affect whole or only portion of the system? Size of system experiencing change; e.g. geography, numbers of people Refs: Mohrman A. et. al. Large-Scale Organizational Change. Jossey-Bass, 1989 and Levy A. Second-order planned change: definitions and conceptualizations. Org. Dynamics. Summer 1986, 15:5-20
    11. 11. Large scale change usually fails Source: McKinsey Performance Transformation Survey, 3000 respondents to global, multi-industry survey of company executives 70% 25% 5%
    12. 12. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
    13. 13. Levers for change What happens ...
    14. 14. Levers for change What happens ...
    15. 15. Levers for change What happens ...
    16. 16. Levers for change What happens ...
    17. 17. Levers for change What happens ...
    18. 18. Levers for change Very few of our „wicked‟ problems will be addressed by believing the health and care system is a machine. Our experience shows that it behaves like a complex social organism. It is time for a different paradigm of large scale change…
    19. 19. Complex Complicated Chaotic Simple Emergent practice Good practice Best practiceNovel practice Snowden D & Benford RD. The Cynefin Framework. Cause & effect relationships exist, are obvious to most people & predictable & repeatable. Can be known in advance. Cause & effect relationships exist, but not obvious, so require analysis/investigation +/- expert knowledge. Cause & effect only obvious in hindsight, with unpredictable, emergent outcomes. No cause & effect relationships can be determined. Probe. Sense. Respond. Sense. Analyse. Respond. Sense. Categorise. Respond.Act. Sense. Respond. Knowable Known Disorder Several options
    20. 20. www.youtube.com/watch?v=ctMty7av0jc Coordinated, behaviour – thousands of birds moving ‘as one’ – with no external control How? A small number of simple rules, internalised: • Separation: steer to avoid crowding local flockmates, • Alignment: steer towards the average heading of local flockmates, and • Cohesion: steer to move toward the average position of local flockmates .
    21. 21. Leading in complexity  A small number of simple rules  Acting within each unit  A few well-tested external influences & barriers
    22. 22. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
    23. 23. A different paradigm
    24. 24. What’s the financial incentive? Who is performance managing? What’s the project plan?
    25. 25. “I have some KPIs for your” or “I have a dream”
    26. 26. “You can’t impose anything on anyone and expect them to be committed to it” Edgar Schein Professor Emeritus, MIT Sloan School
    27. 27. Drivers of extrinsic motivation  regulation  payment & incentive systems  performance management  measurement for accountability create focus & momentum for delivery Intrinsic motivators  connecting to shared purpose  engaging, mobilising and calling to action  motivational leadership build energy and creativity
    28. 28. build energy and creativity Internal motivators  connecting to  shared purpose  engaging, mobilising and calling to action  motivational leadership Drivers of extrinsic motivation  System drivers & incentives  Performance management  Measurement for accountability create & focus momentum for delivery
    29. 29. How do we create shared purpose? Identify shared values Create a safe space Create a vision for the future Describe why the change is urgent now Amended from work by Roffey Park
    30. 30. [Shared] purpose goes way deeper than vision and mission; it goes right into your gut and taps some part of your primal self. I believe that if you can bring people with similar primal-purposes together and get them all marching in the same direction, amazing things can be achieved. Seth Garguilo
    31. 31. Using shared purpose The „why‟ of your change A gravitational force for drivers The fuel that won‟t run out A uniting force for stakeholders
    32. 32. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
    33. 33. Complex Complicated Chaotic Simple Emergent practice Good practice Best practiceNovel practice Snowden D & Benford RD. The Cynefin Framework. Cause & effect relationships exist, are obvious to most people & predictable & repeatable. Can be known in advance. Cause & effect relationships exist, but not obvious, so require analysis/investigation +/- expert knowledge. Cause & effect only obvious in hindsight, with unpredictable, emergent outcomes. No cause & effect relationships can be determined. Probe. Sense. Respond. Sense. Analyse. Respond. Sense. Categorise. Respond.Act. Sense. Respond. Disorder
    34. 34. Sequencing in large scale change Identifying need for change Framing/ reframing the issues Engaging/ connecting others Making pragmatic change in multiple processes Attracting further interest After some time Settling in Possible outcomes 1. sustainable norm 2. plateau 3. run out of energy Living with results and consequences Maybe later Repeats many times in hard to predict ways Time delay
    35. 35. Large Scale Change The emergent process of mobilising a large collection of individuals, groups and organisations toward a vision of a fundamentally new future state, by means of: • high-leverage key themes • a shift in power and a more distributed leadership • massive and active engagement of stakeholders • mutually reinforcing changes in multiple factors • a focus on changing patterns of behaviour, relationship & power
    36. 36. Leading large scale change for integrated care  The story so far  Change in complexity  Creating shared purpose  Sequencing  Top tips
    37. 37. Conclusions from the evidence Successful integration requires: • shared purpose & collaborative behaviours, more than new structures • overcoming silos through communication (leaders & staff talking, shared patient record, shared performance data) • much can be done within existing regimes (eg tariff, Caldicott) • no silver bullet bit.ly/RzENMB
    38. 38. Conclusions from the evidence “Leaders and managers tasked with applying integrated care „at scale and pace‟ might … focus on driving forward the organisational solution or introduce various financial inducements in the hope this will be more effective [than starting with values-based shared purpose]. Such an approach would be a mistake… A values-driven approach should be a pre-requisite to the successful adoption of integrated care.” Goodwin, Nick. “Taking Integrated Care Forward: The Need for Shared Values.” International Journal of Integrated Care 13, no. 2 (June 24, 2013).
    39. 39. Conclusions from the evidence • Eventually, successful commissioners have to adopt different approaches: • see the whole system, not just constituent services • more relational, less transactional • more clinically-led collaboration with providers, less finance-led negotiation • more provider-led innovation & improvement • less bound by annual & linear cycles, more flexible, long-term & iterative bit.ly/13Otdyq
    40. 40. Top tips (NHS Academy for Large Scale Change) 1. Moving towards a new vision that is better and fundamentally different from the status quo 2. Identifying and communicating key themes that people can relate to and that will make a big difference 3. Multiples of things („lots of lots‟) 4. Framing the issues in ways that engage and mobilise the imagination, energy and will of a large number of diverse stakeholders 5. Mutually reinforcing change across multiple processes/subsystems
    41. 41. Top tips (NHS Academy for Large Scale Change) 1. Continually refreshing the story and attracting new, active supporters 2. Emergent planning and design, based on monitoring progress and adapting as you go 3. Enabling many people to contribute to the leadership of change, beyond organisational boundaries 4. Transforming mindsets, leading to inherently sustainable change 5. Maintaining and refreshing the leaders‟ energy over the long haul
    42. 42. bit.ly/1fBri9W bit.ly/1fUNUkl slidesha.re/1pSSbJh enquiries@nhsiq.nhs.net @robertvarnam

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