Rewriting the Rules: Enduring and Emerging Approaches to Change

#RTR2016
@HelenBevan #RTR2016
1. Identify major themes and trends in the global world of
change that are starting to shake our world of healthcare
improvement
2. Consider the implications for our own practice as leaders
and practitioners of change and improvement
3. Test out some of the new change methods and
approaches in an interactive way
4. Consider the opportunities and implications
of these for our own practice as leaders of
healthcare improvement
5. Take home a toolkit of new and additional
approaches to supporting change to complement your
existing healthcare improvement toolkit and make your
improvement efforts more likely to succeed

#RTR2016
• Welcome and introductions; outline of the day
• What’s our message for today?
• What is happening in the wider world of change?
• Why this is the era of the healthcare rebel
• Coffee break in the form of a RCT (randomised coffee trial)
• Change starts with me
• Lunch
• Rolling with resistance to change
• Leading change in a complex world: managing polarities
(including coffee)
• Sharing lessons learnt

#RTR2016
What is your slogan for today?

#RTR2016
“New truths begin as heresies”
(Huxley, defending Darwin’s theory of natural selection)
Source of image:
installation by the
artist Adam Katz
www.thisiscolossal.com
Via @NeilPerkin

#RTR2016
What are the big themes for change in
the world in which we now operate?
“Linear thinking does not prepare us for exponential times”
Dion Hinchcliffe

#RTR2016
Change is changing

#RTR2016
What approaches to change are needed
in this environment?

#RTR2016
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

#RTR2016
Source: Bromford P (2015), ”What’s the difference between a test and a pilot?”
Pilots are being replaced by rapid tests and
prototypes

#RTR2016
Digital skills are a critical capability for future leaders of
improvement

#RTR2016
How does the NHS improvement community
prefer to communicate?
Digital
Non-digital
ProactiveReactive
Source: RAND evaluation data from the Q community of improvement leaders

#RTR2016
Change is changing
Change is moving to
the edge

#RTR2016
An example from the
Cabinet Office
http://www.slideshare.net/Openpolicymaking/060715-change-cardscollated?next_slideshow=1

#RTR2016
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

#RTR2016
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

#RTR2016
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

#RTR2016
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

#RTR2016
List A
Programme Board
Office
streams
• The Clinical Director
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

#RTR2016
List A
Programme Board
Office
streams
• The Project Manager
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

#RTR2016
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

#RTR2016
Is your change process a cathedral or a bazaar?
http://www.unterstein.net/su/docs/CathBaz.pdf

#RTR2016
We have a lot of cathedrals
Source: Sewell (2015) : Stop training our project managers to be process junkies

#RTR2016
Power in community
“Power used to come largely through and from big
institutions.
Today power can and does come from connected individuals
in community.
When community invests in an idea, it co-owns its success.
Source of image: orton.org
Instead of trying to
achieve scale all by
ourselves, we have a new
way to have scale. Scale
can be in, with and
through community.”
Nilofer Merchant

#RTR2016
“I have some Key
Performance
Indicators
for you”
or
“I have a
dream”
Source: @RobertVarnam

#RTR2016
“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!

#RTR2016
“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
“The single biggest mistake to
avoid? Creating disruption at work.
Focus on developing relationships,
not disrupting and alienating
people. Peter Vander Awera on
learning from setbacks and failures
is the new normal!
##FabChangeDay

#RTR2016
What happens to
heretics/radicals/rebels/mavericks
in organisations?

#RTR2016
@HelenBevan #RTR2016Source: Lois Kelly http://www.slideshare.net/Foghound/rocking-the-boat-without-falling-out

#RTR2016
We need rebels!
•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

#RTR2016
If you put fences around people, you
get sheep. Give people the room they
need
William L McKnight

#RTR2016
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

#RTR2016
Source : Lois Kelly www.foghound.com
There’s a big difference between a rebel and a
troublemaker
Rebel

#RTR2016
Reflection
• What are your insights around “rebels” and
“troublemakers”?
• What moves people from being “rebel” to
“troublemaker”?
• How do we protect against this?

#RTR2016
Source : Lois Kelly www.rebelsatwork.com
There’s a big difference between a rebel
and a troublemaker
Rebel

#RTR2016
For our break, we will
have a RCT

#RTR2016
• Randomised Coffee Trial!
• Randomised Coffee Trial!
Randomised Coffee Trial!

#RTR2016
Outcomes of Randomised Coffee Trials

#RTR2016
fabnhsstuff.net/fabchangeday/rct/ or google “Fab stuff RCT”

#RTR2016
Join in one of our national Randomised Coffee
Trials
fabnhsstuff.net/fabchangeday/rct/ or google “Fab stuff RCT”
Mental health – for anyone interested in mental health issues
Dementia – for anyone interested in dementia issues
Staff wellbeing – for anyone interested in how staff are cared for
Patient Safety – for anyone with an interest in ensuring patient
safety across the health and social care system
Home First – looking at the issues around how people who have
long-term health conditions receive care outside of hospital
Learning and Leading Together – for anyone interested in how
patients and healthcare staff can work together in genuine
partnership
MatExp – for anyone interested in improving maternity experience
– women and families as well as professionals

#RTR2016
Sign up for action with the Fab Change Day app
app.fabchangeday.net

#RTR2016
Change starts with me
Source of image: jasonkeath.com

#RTR2016
‘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

#RTR2016
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 “self-efficacy”
 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

#RTR2016
Self-efficacy
There is a positive, significant
relationship between the
self-efficacy beliefs of a
change agent and her/his
ability to facilitate change
and get good outcomes
Source of image:www.h3daily.com

#RTR2016
Source: @NHSChangeDay

#RTR2016
Source: @NHSChangeDay
What is the issue here?
“permission” ?
(externally generated)
or
Self efficacy ?
(internally generated)

#RTR2016
Building self-efficacy: 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

#RTR2016
@HelenBevan #RTR2016Image copyright: http://13c4.wordpress.com/2007/02/24/50-reasons-not-to-change/

#RTR2016
C http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively

#RTR2016
@HelenBevan #RTR2016Source: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively

#RTR2016
@HelenBevan #RTR2016Source: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively
Make it a personal
PERFORMANCE target.

#RTR2016
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 twelfth contact
Source: http://www.slideshare.net/bryandaly/go-for-no

#RTR2016
“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.
—

#SHCR @HelenBevan#@HelenBevan
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”.

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 :
Out-love everyone else
Source of image: Bradley Burgess

“Stages of change”
Transtheoretical model of behaviour change
Prochaska, DiClemente & Norcross (1992)

• 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

Smoking
I am not aware my
smoking is a
problem – I have no
intention to quit

Smoking
I am not aware my
smoking is a
intention to quit
I know my smoking
is a problem – I
want to stop but no
plans yet

I am not aware my
smoking is a
intention to quit
I know my smoking
is a problem – I
want to stop but no
plans yet
I am making plans
& changing things
I do in
preparation.
Smoking

I am not aware my
smoking is a
intention to quit
I know my smoking
is a problem – I
want to stop but no
plans yet
I am making plans
& changing things
I do in
preparation.
I have
stopped
smoking!
Smoking

I am not aware my
smoking is a
intention to quit
I know my smoking
is a problem – I
want to stop but no
plans yet
I am making plans
& changing things
I do in
preparation.
I have
stopped
smoking!
I am continuing to
not smoke.
I sometimes miss it
– but I am still not
smoking
Smoking

Transtheoretical model of behaviour change

• 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

#SHCR @HelenBevan#IQTGOLD@HelenBevan
• 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

“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?

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

• 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 it
Cherokee proverb
Source of image: fenwickgallery.co.uk
‘‘

Focussing on Prochaska, DiClemente and
Norcross’s Stages of Change model:
• What stage of change are some of the key
people that you need to influence for your
change initiative at?
• What actions can you take to help them move
to the next stage?
Thinking about your own situation

“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

“Every conflict
is an invitation
to innovation.”
Mary Parker Follett
Sociologist, 1868-1933

#SHCR @HelenBevan#IQTGOLD@HelenBevan@HelenBevan

Polarities in today’s workshop
Old power AND New power
List A AND List B
Hierarchies AND Networks
Transactions AND Relationships
At the edge AND In the centre
On the inside AND On the outside
Change methods AND Emergent change

Polarity map concept
Source: Barry Johnson
+
–
New powerOld power

Polarity map concept
Source: Barry Johnson
Centralise Decentralise
+
–
Centralise DecentraliseDecentraliseCentralise
Either-Or

Q is a thriving, effective community of improvement leaders
The Q community fails to fulfil its potential
Example

Positive results of focus on this left pole
Negative results of over-focus on the
left pole to the neglect of the right pole
Negative results of over-focus on the
right pole to the neglect of the left pole
Deeper Fear from lack of balance
Greater Purpose Statement - why balance this polarity?
*
and
Adapted from the Polarity Management map, Polarity Associates
PolarityMapAction steps
How will we gain or maintain the positive
results from focusing on this left pole?
What? Who? By When? Measures?
Action Steps
How will we gain or maintain the positive
results from focusing on this right pole?
What? Who? By When? Measures?
Early Warnings
Measurable indicators (things you can count)
that will let you know that you are getting into
the downside of this left pole.
Early Warnings
Measurable indicators (things you can
count) that will let you know that you are
getting into the downside of this right pole.
Positive results of focus on this right pole

Rewriting the Rules: Enduring and Emerging Approaches to Change

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Rewriting the Rules: Enduring and Emerging Approaches to Change