NHS Graduate Trainees: Change and Transformation - Zoe Lord & Leigh Kendall

@horizonsnhs
The Horizons team:
Change agents and change
agency
• A small, diverse team of people within
the NHS that supports change agents
and builds change agency
• We tune into the latest change thinking and
practice in healthcare and other industries
around the world
• The team has emerged through years of supporting
change in the NHS and the wider health and care system

@horizonsnhs
Housekeeping and survival!
Breaks…
Fire alarms and exits…
Mobile
technology
Toilet
location…
Security…
WWW & EBI
Lunch…

@horizonsnhs
Plan for the day
• Welcome and intros
– Who are Horizons?
• Plan for today…
– Why is change important?
– What do we know about change?
– What’s changing in the world of change!
– Resistance to change
– Communicating for effective influence
– Energy for change
– TRIZ
– 6 thinking hats
• Close 3pm
Does this cover what
you want to get out
of today?

How do YOU feel about change?
If you feel…
Go to the right
If you feel…
Go to the left

How do think FRONT LINE STAFF
feel about change to
structure and services?
If you think they feel…
Go to the right
Go to the left

How do think PATIENTS
feel about change to their local services?
Go to the right
Go to the left

How do think YOUR CURRENT MANAGER
feels about change?
Go to the right
Go to the left

Attitudes to change differ…
Proportionate
enthusiasm
Healthy
scepticism
Annoying
evangelism
Irrational
obstructionism
Moderate
interest

Attitudes to change
Proportionate
enthusiasm
Healthy
scepticism
Annoying
evangelism
Irrational
obstructionism
Moderate
interest
Calming down
Keeping in real world
Perspective
Focussing ?
Support
Direction
Feedback
Motivating
Exploring
Evidence of benefit
“Unpacking”
Debate (argument)
Selling

People adopt ideas and innovations at different speeds
Change Adoption
Speed of Adoption LowHigh
Innovators
2.5%
Early Adopters
13.5%
Laggards
16%
Early
Majority
34%
Late
Majority
34%
Start with enthusiasts – but choose carefully

@horizonsnhs
What do we know about change and
how to go about it?

Even if you have the best idea –
why doesn’t change happen?

Why do change programmes
fail?

@horizonsnhs
Why do people resist change?

@horizonsnhs
What do resistant behaviours look
like?

@horizonsnhs
Mark Jaben on the science behind
resistance
What NOT to do
But what we do do
Engage
people here

@horizonsnhs
Mark Jaben on the science behind
resistance
What NOT to do
Instead of buyers (who “buy-in”),
we need investors
What TO do
Engage
people here
Engage
people here

@horizonsnhs
One size fits all???

@horizonsnhs
Choose an appropriate approach
Just do it
Innovate
Test and
replicate
CLEAR
COMPLEX
CHAOTIC
COMPLICATED
Source: Lisa Schilling
1
1
4

What models or tools can we use
for the purposes of effective
change?

Aims
Measurements
Change ideas
The Improvement Guide
Langley et al (1996)
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make that will
result in the improvements that we seek
?
Model for Improvement
Act Plan
Study Do
Testing ideas before
implementing changes

@horizonsnhs
Plan Do ActStudy
However, in this context, PDSA
is:
…how to
explicitly
test a small
change
…what you
have
planned to
do
…the
outcomes,
expected
and
unexpected,
of the test
…on the
results to
modify and
improve

@horizonsnhs
:We’ve all done at least
one PDSA!

@horizonsnhs
Testing and
refining ideas
Implementing new
procedures & systems
- sustaining change
Bright
idea!
Developing
improvement
with PDSAs

@horizonsnhs
Bright
idea!
Improvement
Improvement
?
?
Improvement
?
?
?
?

@horizonsnhs
Change Model
• Connect with shared
purpose
• Commitment not
compliance
• Lead with the why, the
passion & intrinsic
motivation
Source: Leading Large Scale Change

@horizonsnhs
Blended approaches
• Lean
• 6 sigma
• Prince 2

How the world is changing isn't
often reflected in plans…
34

@horizonsnhs
Jeremy Heimens, Henry Timms
This is New Power
old power new power
Currency
Held by a few
Pushed down
Commanded
Closed
Transaction
Current
Made by many
Pulled in
Shared
Open
Relationship

@horizonsnhs
The predominant approach in recent years has been STRUCTURE
but globally there is a big shift towards AGENCY
The design dilemma at the heart of change &
implementation

@horizonsnhs
Source: @NHSChangeDay

@horizonsnhs
Source: @NHSChangeDay
Problematic:
changing a
“permission
culture” can
take years
The good news:
we can usually
build agency
much more
quickly

@horizonsnhs
The people making change happen is
changing
42
Source: adapted by Helen Bevan from
Leandro Herrera
List A
• The Delivery Board
• The programme sponsors
• The programme
management office
• The work stream leads
• The Clinical Leads
• The Directors of
participating functions
• The Change Facilitators

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

@horizonsnhs
changing
44
List B
• The mavericks and rebels
• The deviants (positive). Who do
things differently and succeed
• The nonconformists who see
things through glasses no one else
has
• The hyper-connected who 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
onesSource: adapted by Helen Bevan from
Leandro Herrera
List A
• The programme
management office

@horizonsnhs
changing
45
List B
• The mavericks and rebels
• The deviants (positive). Who do
things differently and succeed
• The nonconformists who see
things through glasses no one else
has
• The hyper-connected who 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
onesSource: adapted by Helen Bevan from
Leandro Herrera
List A
• The programme
management office

@horizonsnhs
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 and systems
affected by change

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

@horizonsnhs
To stay in touch, connect with the
3%
Just 3% of people in
the organisation or
system typically
drive conversations
with 90% of the
other people
Source: research by Innovisor

@horizonsnhs
Tool for building networks:
Randomised coffee trials
Image source: Pinterest

@horizonsnhs
Randomised Coffee Trials #RCT
Download resources for your RCT:
https://www.slideshare.net/HorizonsCIC/how-to-set-up-a-
randomised-coffee-trial

We now have the people, the
groups, the networks…
how are we going to work
with them?

@horizonsnhs
Transtheoretical model of behaviour
change
Prochaska, DiClemente & Norcross (1992)

@horizonsnhs
The model has been used with
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!

What qualities make
an effective communicator?
Communicating
for effective influence

What qualities make
an effective communicator?
Listening
Observing
Empathy
Questioning
Being present
Talking

“To effectively communicate,
we must realise that we are all
different in the way we
perceive the world and use this
understanding as a guide to
our communication with others.”
Anthony Robbins

What is emotional intelligence (EQ)?

What you say (or what you
believe you are saying!)
What is
heard/
understood
Expectations Hopes
Fears
Previous
experiences
Prejudice
Mood/state of mind
Distractions –
internal and
external
Assumptions

“The single biggest problem
in communication is the
illusion that it
has taken place.”
George Bernard Shaw

“The biggest
communication problem is
that we do not listen to
understand.
We listen to reply.”

Listening attentively – am I giving my full attention?
Listening accurately – am I understanding what they
are saying?
Listening empathetically – do I really appreciate
their feelings?
Listen generatively – are you helping the other
person through your dialogue?
Ways of Listening

Reflecting – word for word
Summarising– precis of their words
Paraphrasing – putting their words in to mine
Pre-framing– “I think I heard you say…”
“Or in other words…”
Ways of Demonstrating you are
Listening

Transactional analysis
Parent
Adult
Child
Safe
Calming
Nurturing
Supportive
Reasonable
Equitable
Logical
Non-
threatening
Curious
Playful
Spontaneous
Creativity
Negative
Controlling
Critical
Patronising
Directive
Tantrums
Lack of responsibility
Insecure
Difficult
Positive

Interactional
Small talk
Polite, fills a gap.
You might say
nothing of
importance.
Person might not
be listening.
Doesn’t really
achieve
anything.
Transactional
Asking someone
to do something
for you.
Ordering a
coffee.
Polite
(hopefully!) and
(hopefully!)
achieves
accomplishing a
task.
Transformational
Engaging in genuine
dialogue.
Involves proper
listening.
Might be
uncomfortable.
Increases our awareness
and understanding.
Builds trust and rapport.
Creates a shift, a
change.

@horizonsnhs
Personal styles
Analytical
•formal
•measured + systematic
•seek accuracy / precision
•dislike unpredictability and surprises
Driver
•business like
•fast + decisive
•seek control
•dislike inefficiency and indecision
Amiable
•conforming
•less rushed + easy going
•seek appreciation
•dislike insensitivity and impatience
Expressive
•flamboyant
•fast + spontaneous
•seek recognition
•dislike routine and boredom
Controls
emotions
Ask Tell
Shows
emotions Merrill D, Reid R (1991) Personal Styles and Effective
Performance, CRC Press, London

@horizonsnhs
So What?
• Nature of social media means content is
fleeting, even viral content.
• Millions of people might have seen your
content, but has it had an impact? How do
you know?
OR

@horizonsnhs
Spread and Reach
• Focus on maximising spread and reach,
rather than trying to ‘go viral’.
• Share good content that is consistent with
your brand
• Find your people – communities, social
movements, hashtags
• Calls to action

@horizonsnhs
Influence
…but numbers are not the whole picture.
What is the story behind the numbers?
What impact have you had?

@horizonsnhs
Influence and Impact
It IS about
• Engagement: starting
conversations
• Communities: like-minded
people collaborating
• Quality, not quantity
• Generosity and support
• Inclusivity: all voices are
welcome
• Authenticity, not ‘playing the
game’
(and these factors are why #MatExp works so well on Twitter)

@horizonsnhs
Activity!
How does your current Twitter brand fit
with what you want to be known for?
Think about
• Do you need to make any
changes?
• If yes, what changes will
they be?
• How will you action those
changes?
• Think SMART goals

@horizonsnhs
Maximise your reach, spread,
influence and impact
• Be authentic
• Be generous – be kind, give advice, share
interesting content
• Pump up the volume: use
complementary platforms such as blogs,
Steller, Storify to give your messages and
voice longevity (this can also help you
become a thought leader in your area of
specialism).

@horizonsnhs
What kind of content has the
best reach and spread?
• Stories with high
emotion – whether
happiness or anger
• The WOW or aaah
factor
• Social currency

@horizonsnhs
Twitter Turn Ons
• Be polite
• Be kind
• Be relevant
• Be authentic
• Engage
• Find your people
• Share relevant
content
• Say thanks, give
credit where due
• Me, me, me
• Keep saying the same
thing again and again
and again….
• Cliques
• Rudeness
• Broadcasting, no
interaction
• Auto-DMs
Twitter Turn Offs

@horizonsnhs
Lessons from
Twitter Fails
Beware automated tweets
Sense check your hashtags!
Giraffes don’t live in Ghana
If you engage professional PR support,
don’t make it look too obvious!

“Energy for change” is defined as
The capacity and drive of a
team, organisation or
system to act and make the
difference necessary to
achieve its goals http://www.institute.nhs.uk/tools/energy_for
_change/energy_for_change_.html
#beingvisible

Energy is the strength and vitality
required for sustained physical or
mental activity.
Change: Make or become different
#beingvisible

Teams perform best when
five energies are high
Psychological
Physical
Spiritual
Social Intellectual
Source: http://www.institute.nhs.uk/tools/energy_for_change/energy_for_change_.html
#beingvisible

Social Energy
Energy of personal engagement,
relationships and
connections between people
It’s where people feel a
sense of
“us and us”
rather than
“us and them”
#beingvisible

Spiritual energy
Energy of commitment to a
common vision for the future,
driven by shared values and a
higher purpose
Gives people the confidence to move
towards a different future that is more
compelling than the status quo
#beingvisible

Psychological energy
Energy of courage,
resilience and feeling
safe to do things
differently
Involves feeling supported to
make a change and trust in
leadership and direction
#beingvisible

Physical energy
Energy of action,
getting things done
and making progress
The flexible, responsive drive
to make things happen
#beingvisible

Intellectual energy
Energy of analysis, planning
and thinking
Involves gaining insight as well as planning and
supporting processes, evaluation, and arguing a case
on the basis of logic/evidence
#beingvisible

High and low ends of each
energy domain
Social isolated solidarity
Spiritual uncommitted higher purpose
Psychological risky safe
Physical fatigue vitality
Intellectual Illogical reason
HIGHLOW
#beingvisible

1
2
3
4
5
Social
Spiritual
PsychologicalPhysical
Intellectual
Team 1:
What’s your
assessment of their
energy for change?
#beingvisible

The challenge of
disproportionately high
intellectual energy
Intellectual energy on its own isn’t transformational
It keeps leaders in their comfort zone (intellect to intellect)
#beingvisible

What is the energy in
your team like?
#beingvisible

What can YOU do to
improve energies in your team?
#beingvisible

Tools…
• Brainstorming through different viewpoints:
Fresh eyes
• De bono’s 6 thinking hats
• Liberating Structures: TRIZ

@horizonsnhs
TRIZ
• It’s a Russian acronym:
“Teoriya Resheniya Izobretatelskikh Zadach”
• A problem solving, analysis and forecasting tool.
• Depersonalising and unpicking topics that people
are passionate about.
• Part of ‘Liberating Structures’
– Frameworks that make it possible for people and
organisations to create, do new things, to be
innovative.

@horizonsnhs
TRIZ
How could we could reliably create a
trainee programme that NEVER works
and is totally ineffective?
TRIZ

@horizonsnhs
Step 1
As a table, make a list of all the things that we could
do to ensure we meet our goal:
How could we could reliably create a trainee
programme that NEVER works and is totally
ineffective?
• Go wild!
• Use post it notes (one per action!)
• 10 minutes
TRIZ

@horizonsnhs
Step 2
As a table group, go down your first list and ask:
Is there anything that we are currently doing that
in any way, shape or form resembles any of the
actions on your post it notes?
• If yes, move these post it notes to sheet 2.
• Be unforgiving about these items and talk about
their impact
• 10 minutes
TRIZ

@horizonsnhs
Step 3
As a table group, go down your second list from
step 2 and ask:
What could be stopped?
• Take these post it notes and move them to
sheet 3.
• 10 minutes
TRIZ

@horizonsnhs
Step 4
From the actions that can be stopped, discuss and
create an action plan for the stopping these
activities.
• 10 minutes
TRIZ

The Change Challenge
Tapping the collective brilliance
of the NHS

14,000 contributions identified
10 barriers to change:
Confusing strategies
Over controlling
leadership
Perverse incentivesStifling innovation
Poor workforce
planning
One way
communication
Inhibiting
environment
Undervaluing staff
Poor project
management
Playing it safe
Source: Health Service Journal, Nursing Times, NHS Improving Quality, “Change Challenge” March 2015

@horizonsnhs
Front line teams get inundated with high
priority messages from leaders each day,
making it difficult for them to know what to
focus on
Increasing number of messages
as information cascade through
the organisation
Source: adapted from
http://businessjournal.gallup.com/content/162707/change-initiatives-fail-
don.aspx

14,000 contributions identified
11 building blocks for change:
Inspiring & supportive
leadership
Collaborative working
Thought diversityAutonomy & trust
Smart use of resources
Flexibility &
adaptability
Long term thinking
Nurturing our people
Fostering an open
culture
A call to action
Source: Health Service Journal, Nursing Times, NHS Improving
Quality, “Change Challenge” March 2015
Challenging the
status quo

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

NHS Graduate Trainees: Change and Transformation - Zoe Lord & Leigh Kendall

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