Catalyzing students and trainees as agents of change

Catalyzing Students
and Trainees as
Agents of Change
IHI Middle East Forum
The presenters have
nothing to disclose
Friday, March 23, 2018
Dr. Kate B. Hilton & Dr. Helen Bevan
@KateBHilton @HelenBevan

@KateBHilton @HelenBevan #MEForum2018
Who is in the room?
Tell the people at your
table:
• Who you are
• Where you are from
• What you hope to
learn today
In one breath!

Getting to know each other
Go to the corner that identifies you
Back of the room
Screen and front
of the room
Student
A
Healthcare
professional
B
Resident
C
Educator or
something else
DWhat is your role?

I’m involved in
quality
improvement but
not with students
A
I engage with
many students in
quality
improvement
B
To what extent are you working with students?
I am not involved in
quality improvement
project(s) C
I engage with a
few students in
quality
improvement
D

Getting to know each other
I am familiar with
community
organizing
principles C
I look forward to
learning more
about
community
organizing
D
I regularly use
community
organizing in my
improvement
work A
I have used
community
organizing in the
past B

Dr. Kate Hilton, JD, MTS
Faculty, IHI Open School, ReThink
Health & George Washington University
Kate Hilton & Helen Bevan
Dr. Helen Bevan, PhD
Chief Transformation Officer
NHS Horizons

Session Objectives
Appreciate the powerful role that students and
residents can play in the transformation of health
and health care
Understand the skills of an effective change agent
and how to build them
Describe the design and implementation of a
community, action-oriented campaign effort in the
context of quality improvement

Agenda
Time Activity
1:00-1:30 pm Introductions, Objectives & Agreements
1:30-2:15 pm The Role of the Change Agent
2:15-2:45 pm IHI Open School
2:45-3:15 pm Break & Randomized Coffee Trial (RCT)
3:15-4:45 pm Four Organising Practices
4:45-5:00 pm Wrap Up

Agreements
Start / end on time (end early whenever possible)
Be as present as possible
Speak for self, listen openly, embrace differences
Step up, step back
Lean into uncertainty & hold tension by turning to
wonder
“Try on” and invite “Middle East moments”
Have fun!

“A Swedish moment”

“Middle East moments”

The Role of the
Change Agent

The Horizons team:
Change agents and change agency
• We tune into the latest change thinking
and practice in healthcare and other
industries around the world –translating
this learning into practical approaches to
change
• The team has emerged
through years of supporting
change in the NHS and
health and care system
• A small, diverse team of people within the English
National Health Service

Change AGENCY definition:
The power, individually and collectively, to make
a positive difference. It is about pushing the
boundaries of what is possible, mobilising
others and making change happen more quickly
Change AGENT definition:
Someone who is actively developing the skills,
confidence, power, relationships and courage to
make a positive difference

@helenbevan #MEForum2018
Being a change agent
is about building power for change
Power is one’s
ability to achieve
goals.
Bertrand Russell

Jeremy Heimens, Henry Timms New Power: How it’s changing the 21st Century and why you
need to know (2018)
Current
Made by many
Pulled in
Shared
Open
Relationship
old power
Currency
Held by a few
Pushed down
Commanded
Closed
Transaction
new power

If people give to a cause, they expect a
relationship, not a transaction.
Nilofer Merchant

The Network Secrets of Great
Change Agents
Julie Battilana & Tiziana Casciaro
As a change agent, my centrality in the
informal network is more important than
my position in the formal hierarchy

Find the 3%!
Just 3% of people in the organisation or system
typically influence 85% of the other people
Source: Organisational Network Analysis by Innovisor

People who are highly connected
have twice as much power to
influence change as people with
hierarchical power
Leandro Herrero
http://t.co/Du6zCbrDBC

Starts on the fringe
(at the edge)
Starts with the activists
Gary Hamel
always

We need rebels!
•The principal champion of a change initiative, cause
or action
•Rebels don’t wait for permission to lead, innovate,
strategise
•They point to new horizons
•They are responsible; they do what is right
•They name things that others don’t see yet
•Without rebels, the storyline never changes
Source : @PeterVan http://t.co/6CQtA4wUv1

If you put fences around people, you
get sheep. Give people the room they
need.
William L McKnight

What happens to
rebels/heretics/radicals/mavericks
in organisations?
Source of image: thinglink.com
?

Source: Lois Kelly http://www.slideshare.net/Foghound/rocking-the-boat-without-falling-out

We need to be boatrockers!
Source: Debra Meyerson
• Rock the boat but manage to stay in
it
• Walk the fine line between difference
and fit, inside and outside
• Able to challenge the status quo
when we see that there could be a
better way
• Conform AND rebel
• Capable of working with others to
create success NOT perceived by
others as a destructive troublemaker

Source: adapted from Rebels at Work

“A cynic, after all, is a
passionate person who
does not want to be
disappointed again.”
Source of graphic: Benjamin Zander’s TED talk

Source of image: Tord the Meme
by Marley Bryn
The world feels
terrible if I
choose to
distrust it
Marcella Bremer

Reflection
• What are your insights around “boatrocking”
and “falling out”?
• What moves people from being “boatrockers” to
“falling out”?
• How do we protect against this?

More reading
Source of graphic : Umair Haque
Lois Kelly and Carmen Medina The rebel at work handbook
Harvey Schachter How to be a rebel, not a troublemaker at work
Debra Meyerson Tempered radicals: how people use difference to
inspire change at work
Jane Watson A spotter’s guide to rebels and cynics
Umair Haque How to be more loving in a cynical world
Clark Quinn Skeptical optimist or hopeful cynic? A science mindset
Marcella Bremer Cynicism or opticism?

Change starts with me
Source of image: jasonkeath.com

We are not outside of the change:
we ARE the change
Source of graphic: Reos Partners

The success of our actions as change-
makers does not depend on what we do or
how we do it, but on the inner place from
which we operate.”
Otto Scharmer
Leading from the emerging future

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. strong sense of agency
 belief that I am personally able/have the
power to create the change
4. more likely to view obstacles as challenges to
overcome
Four things we know about
successful boat rockers
Source: adapted from Debra E Meyerson

Making sure that only people who
should be in hospital are in hospital
• The number of hospital beds occupied by patients
whose transfer of care has been delayed should be
reduced to 3.5%
• Less than 15% of assessments [for continuing care]
should take place in an acute hospital setting;
• A standardised performance dashboard

Royal Devon and Exeter Hospital

University Hospitals Morecombe Bay

Nine hospitals in the East of England gave
patients back 91,728 days or 250 years’
worth of time

70 day challenge: to
give patients back one
million days of their
precious time that
would otherwise be
wasted in bed in a
hospital or care home.

#endpjparalysis: connected social
communities

Being a great change agent is about
doing, seeing and being change

Avedis Donabedian
Ultimately, the secret of
quality is love…
If you have love, you can
then work backward to
monitor and improve the
system

After years of intensive analysis,
Google discovered that the key to high performing teams
that deliver change is being nice
Project Aristotle: https://www.youtube.com/watch?v=UfGiCnhdU78&feature=youtu.be&list=PLHEw3ja-
xoaZybvz9f0b1_6bJyG7zZO6L

VACANCY: seeking gritty individuals to lead and influence change.
Essential criteria:
• Resilient boat-rocker
• Committed to the development of others
• Comfortable with contradictions and tensions
• Wants to keep learning
• Rolls with resistance and is resilient
• Demonstrates courage in uncertainty
Perks and conditions:
• Extra pay: probably not
• Praise and awards: unlikely
• Respect from others: negotiable
• Energy, purpose and a sense of meaning: guaranteed
Application process: Immediate hiring. Start today.
Position vacant: Change Agent
Developed by Kathryn Perera from original concept by Anne Knock

Overview of the
IHI Open School

IHI Open School Mission
“Advance health care improvement and patient safety
competencies in the current and next generation of
health professionals worldwide.”

IHI Open School Strategy

 32+ online courses developed by world-
renowned experts in the following
topics:
 Improvement Capability
 Patient Safety
 Person- and Family-Centered Care
 Triple Aim for Populations
 Leadership
• Set of GME courses
• More than 550,000 learners have
completed a course
IHI Open School Courses

IHI Open School Courses by the Numbers
32 online courses
More than 3.2 million courses completed
More than 100,000 learners have earned the
Basic Certificate Quality & Safety
More than 1,500 universities & organizations
use the courses for training or curriculum

Open School at HMC
0
2000
4000
6000
8000
10000
12000
14000
Launch Year 1 Year 2 Year 3 Year 4
#ofLearners
Years of Subscription
2014 - 2015
7,528
2015 - 2016
9,692
2013 - 2014
5,623
2016 - 2017
11,797
HMC learners completed 110,000 courses
2018
12,303

IHI Open School Video Library

Middle East Moment:
How have/might IHI
Open School courses
support(ed) you and
your colleagues?

SQOLA 2017 update

International Pledge-A-Thon
October 15 – November 15, 2015
27 Chapters representing 8 countries
5,333 pledges collected
Topics included:
– Flu shots
– Texting and driving
– Advocacy for safe and affordable housing
– Suicide prevention and awareness
– Access to health and wellness services for
students and local community
– Improving one thing for every patient

550,000+ students
and residents
registered
Over 900 Chapters
in more than 90
countries
Allied Health
Professions
Business
Dentistry
Engineering
Health Science
&
Administration
LawMedicine
Nursing
Occupational & Physical
Therapy
Other
Pharmacy
Physician
Assistant
Social Work
IHI Open School Chapter Network

What do Chapters do?
Take IHI Open School courses, and review
them together
Host events at their organization or with other
Chapters in their region
Conduct quality improvement projects
Participate in national campaign efforts
Facilitate activities/learning exercises with
other students, residents, and health
professionals
Participate in educational reform to
incorporate quality and safety into their formal
curriculum

Chapter Network in the Middle East Region
68 Chapters started in 13 countries
Chapters in Qatar, Pakistan, Jordan, Saudi
Arabia, and Kuwait are hosting workshops on
patient safety and quality improvement, and many
are designing formal curriculum on the fundamentals
for staff and/or students.
All are interprofessional – nursing, medicine, health
administration, pharmacy are represented

Connect with a Local Chapter with the
Click of a Button

Middle East Moment:
How might participating
in a Chapter (or similar
interprofessional
network) support your
work with (or as)
students?

Project-Based Learning Programs
Leadership & Organizing for ChangeQuality Improvement Practicum

73
IHI Open School Change Agent Network (I-CAN)
is our community of change agents who are actively
applying the skills they’re learning in quality
improvement, patient safety, community organising,
leadership, and more to improve health and health care
and lead change on their campuses, in clinical settings,
and in their communities.

Leadership & Organising for Change
10-week semi-synchronous online course:
– 30-45 minutes of video lectures
– 60-minute coaching calls
– 1-3 hours application
Change
Improvement
Science
Organizing &
Leadership
Training
Subject
Matter
KnowledgeLearners apply
leadership practices
in field-based
projects to improve
healthLearn more at www.ihi.org/lead

Examples of Projects
Learners have:
• Launched a student-run clinic for the homeless
• Improved access to primary care for refugee
families
• Led a hand-washing compliance campaign
• Partnered with local pharmacies to take back
prescription opioids
• Engaged faculty and administrators to redesign
university curriculum to focus on population health
• Led campaigns to reduce stigma around mental
health

Examples of Projects in the Middle East
Farrukh Zaman, Khyber Medical University – medical students,
residents, and physicians working to lower patients’ BMI
Dr. Manar Khaled, Dar El Shefa Hospital – obstetricians and
neonatologists collaborating with the Ministry of Health and patients and
families to decrease premature births
Dr. Mohammed Shahab Uddin, King Abdulaziz University Hospital –
striving for 100% hand hygiene compliance in the pediatric ICU
Ahmed Mustafa, Armed Forces Hospital Dhahran, Saudi Arabia –
working with clinical staff and IT department to reduce time between
medication ordering and administration to improve safety
Dr. Matiur Rahman, Al Nafees Medical College and Hospital – reducing
healthcare-associated infections through patient safety initiatives & training
Mouna Ayoub Bahsoun, Hamad Medical Corporation – increasing
patient attendance at labor educational sessions to reduce the C-section
rate

Geographic Diversity by Country (Spring 2018)
39 countries
represented
North America 404
Middle East /
Asia / Pacific
103
Latin America 61
Africa 26
UK 13
Europe 2

Impact of the Program
Over 2,000 students, residents,
faculty, and professionals have
engaged with the course
Learners who complete the
program have higher confidence in
their ability to leverage community
organising and leadership skills in
their day-to-day work

Building a Movement to Improve Health
Pledge: >35,000 individuals made
commitments to improve population
health
Learn: >3,000 individuals mobilized by
project teams on campuses and in
communities
Between September 2014 and
December 2015:
Lead: >400 learners took the
course and led a local health
improvement project

Mission: 100 million people living healthier
lives by 2020
Vision: to fundamentally transform the way the
world thinks and acts to improve health, well-
being and equity to get to breakthrough results
Want to get involved? Email openschool@ihi.org

Let’s engage students & residents in rotations and
experiences where they can improve health and
health care in our organizations and communities.

Middle East Moment:
How are you engaging (or
could engage) students and
residents in efforts to
improve health, and how
could you offer them a
greater opportunity to lead?

Break &
Randomized Coffee
Trial (RCT)

For our break, we will have
a RCT

• Randomised Coffee Trial!
Randomized Coffee Trial!

Outcomes of Randomised Coffee Trials

People:
Recruiting and
developing leaders
Power:
Building a community
around those leaders
to create power
Change:
Using this power to
address the challenge the
constituency is called to
face
Community Organizing
… people acting together
to change the status quo
Theory of Change

(1) Who are our People?
(2) What Change do they want?
(3) How can we get the Power we
need to achieve that change?
Organizing = People, Power & Change

System of Profound Knowledge
W. Edwards Deming
Source: The New Economics, W. Edwards Deming
Appreciation
of a System
Knowledge of
Variation
Theory
of Knowledge
Psychology

Psychology
• People have an innate desire to create
value and are our fundamental source of
value
• We must move from systems driven by
fear and extrinsic motivation to those
driven by people’s intrinsic motivation
• Creating a culture that respects people
and treats them as partners takes work
and expertise
W. Edwards Deming

Four Organising
Skills to Effect
Change

Four Organising Skills
1. Know why it matters
2. Build relationships and gain commitment
3. Take a people-based approach
4. Develop a learning community
* Steps developed with Alexandra Nicholas (Ko Awatea), Kate Hilton (ReThink
Health), Jackie Lynton (NHS Change Day), and Jessica Perlo (IHI Open School)

Honouring Jackie Lynton

Deming, Bisognano & What Matters
Fear-driven (extrinsic) motivation is not as
generative or sustainable as intrinsic motivation
To build it, we must understand what matters – what
truly matters – to stakeholders
When what matters is honored, it limits the fears
associated with change because it makes people
more likely to see and experience an improvement’s
fundamental value

What is Public Narrative?
A leadership skill to motivate others to
join us in action

Elements of Public Narrative
Why me? Why now?
WHY US?
CALL TO
ACTION
Why us?

What makes a story?
Challenge – Choice – Outcome

Leaders Motivate Action

Tips: Crafting an Effective Narrative
Specific names
Specific images
Specific sound
Specific smells
Specific moments

Tips: Story of Self
 Share experiences.
 Pick 1-2 choice points that
relate to your calling to be
here today.
 Tell a personal story, in
which YOU are the main
character.
 Be specific, vivid,
clear…see it, hear it, feel it.
 Share what gives you
HOPE!
X Give your resume.
X Tell your whole life
story from birth to
now.
X Tell a story about the
issues only.
X Be abstract.
X Make it all about the
nightmare.
DO: DON’T:

Pair-Sharing – 10 min:
Turn to a partner at your
table and share a story
about why improvement
matters to you

Learning New Skills

In a one-to-one meeting
– Share yours and elicit another person’s story of self
In a team setting or coalition meeting
– As an exercise in a round to ground team in shared
values
In front of a large group
– As a call to collective action
When to Use Public Narrative?

2. Build Relationships &
Gain Commitment

Jeremy Heimens, Henry Timms New Power: How it’s changing the 21st Century and why you
need to know (2018)
Current
Made by many
Pulled in
Shared
Open
Relationship
old power
Currency
Held by a few
Pushed down
Commanded
Closed
Transaction
new power

Short-term treatment (up to six weeks) of
persistent aggression in patients with moderate
to severe Alzheimer’s dementia, unresponsive to
non-pharmacological approaches and when
there is a risk of harm to self or others.
The
guidance
‘

The Reality
Estimated 180,000 people in
England with dementia were
being prescribed antipsychotics
Only 36,000 get any clinical
benefit from the drugs
Negatives far outweigh the
positives
Source: Bannerjee report

“I have some key
performance
indicators for you”
or
“I have a
dream”
Source: @RobertVarnam

Who are our people?
People living with dementia,
families & advocates
Family physicians
Psychiatrists
Pharmacists
Hospital nurses & doctors
Leaders of care homes
Senior decision makers

All people with dementia who are receiving
antipsychotic drugs will have undergone a clinical
review to ensure that if they are receiving these
drugs they are doing so appropriately and that
alternatives to their prescription have been
considered and a shared decision has been agreed
regarding their future care by March 2013.
What do they want?

Each group created an ask
Example: Pharmacists’ group
I (we) commit to:
reviewing the people under my care
to identify those who are prescribed
antipsychotic medication and
working in partnership with my
prescribing and other healthcare
colleagues to review each individual

Who are our people?
• 120 hospital systems engaged
• 700 active members of our virtual community
• 1,800 registrants to our online webinar series
• 2,000 attendees at the national and regional launch events
• 5,000 GPs via and the Royal College of GPs
special interest group
• 25,000 Nurses recruited via the Chief Nursing Officer’s bulletin
and linked via the hospitals group
• 40,000 Pharmacists via the development of the Royal
Pharmaceutical Society resources

Over the next three years
Across the whole of England, a 51% reduction in
prescriptions for antipsychotics for people living
with dementia

How is this approach different
(or additional) ?
• Recruits a broad constituency and
creates a sense of “us” rather than “us
and them”
• Mobilises through a compelling narrative
• Builds many leaders
• Creates commitment to take specific
actions
• Seeks to utilise resources to shift power
to achieve outcomes
• Project team
• Senior sponsorship
• Engages key stakeholders
• Seeks buy-in to change
• Key performance indicators
and milestones
• Accountability through
programme management
system

The learning review/evaluation
To download goo.gl/XsKZ25

Middle East Moment:
Who are your people?
Who (else) does your
improvement work touch?

3. Take a People-Based
Approach

What makes for effective improvement?
ORGANIZATION
Capacity
Created
INDIVIDUAL
Leaders
Developed
AIM
Problem
Solved

Three Aims at Wright State University
1. Aims: Stabilize and reduce the number of people dying
from drug overdoses in Montgomery County.
2. Capacity Built: Launch two projects in which students
can get hands-on QI experience before May 31, 2017.
3. Leadership Developed: Have 20 health professional
student members representing at least 3 different
professional programs involved in the IHI Open School
Chapter through the Student Opioid Coalition by May
31, 2017.
Set a Measurable Aim

How do we unleash our
people?
By how we engage
them in our
relationships!

Reframing the Question
From:
How can I get all these people to do what
I want them to do?
To:
How can I get all these people to do what
they want to do?
Credit: McCannon & Margiotta, Billions Institute

Who Are Our People?
Values: What matters to
you? Why?
Interests: What do you
stand to gain (or lose)?
Assets: What do you bring?

Narcan Training
Session
Event Post Event Networking
Deterra Medication
Disposal System
Grant
Gail Dafler,
Prevention Branch,
COAT
One to One Conversation
Caleb Tang,
Cedarville University
School of Pharmacy
Student
One to One Conversation
50 First Year
Pharmacy Students
Relational Strategies to Gain Commitments

Outcomes to Date
55 students engaged in the Student Opioid Coalition
5 project leaders identified
NARCAN TRAINING EVENT
7+ disciplines involved
(medicine, pharmacy, nursing, SW, public health, professional psychology, pre-medicine)
MEDICATION DISPOSAL KIT
PROJECT
35 students attended
70 doses of Narcan
distributed in the community
40 pharmacy locations
500 disposal kits stocked
Underway: # kits of distributed
HIGH SCHOOL
ATHLETES
Underway:
Student talks

What is Power?
The ability to achieve purpose

5%
Untapped Potential

95%
Untapped Potential

95%
Untapped Potential
x 10

95%
Untapped Potential
x 100

95%
Untapped Potential
x 1,000

95%
Untapped Potential
x 10,000

Middle East Moment:
How does / could
taking a people-based
approach advance
your work?

4. Develop a Learning
Community

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

What is the best way to spread
new knowledge?
Source of data: Nick Milton
http://www.nickmilton.com/2014/10
/why-knowledge-transfer-
through.html
Social connection/discussion is
14 times more effective than
written word/best practice
databases/toolkits etc.
Source of image: www.happiness-one-quote-time.blogspot.com

http://www.nancydixonblog.com/2017/07/the-hidden-knowledge-problem-in-
organizations.html

Source: Michael Arena, Rob Cross, Jonathan Sims, and Ma
Uhl-Bien (2017)
It’s about creating “adaptive spaces” that allow
ideas, information, and resources to flow across
the system and spur improvement
Operational
system
Pockets of
improvement activity

The NHS Continuing Healthcare Collaborative
Approach
The Improvement
Community
200 local groups
The
Development
Group
10 local groups
1000 participants
£100,000 saved
per meeting cycle
1000 ideas and
contributions in 45
minutes
Designed to engage a mass of contributors
right from the start and make the process of
spread much easier

The School for Change Agents
• A virtual learning community
• Runs for 5 weeks every year
• 16,000 people from 53 countries have taken
part
• “How to rock the boat and stay in it”
• External evaluation:
• Had a positive impact on every dimension studies
at both individual and organisational level
• What participants valued most was connecting
with others

The next offering of
the 10-week online
course begins in
September 2018
Contact
info@ihi.org to learn
more
Take a Deeper Dive
into the Concepts
we Shared Today:

Did We Achieve Our Objectives?
After this session, can you:
Appreciate the powerful role that students and residents
can play in the transformation of health and health care?
Understand the skills of an effective change agent and
how to build them?
Describe the design and implementation of a community,
action-oriented campaign effort in the context of quality
improvement?

Our finale: “Snowstorm”
• Write down one key thing you
have learnt from this workshop
on a sheet of white paper

• Write down one key thing you
have learnt from this workshop
on a sheet of white paper
• Screw the paper up

• Write down one key thing you have
learnt from this workshop on a
sheet of white paper
• On the signal, throw your paper
snowball in the air

• Write down one key thing you have learnt
from this workshop on a sheet of white
paper
• On the signal, throw your paper snowball in
the air
• Pick up a snowball that lands near you and
read it aloud to the rest of your table

Catalyzing students and trainees as agents of change

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