School for Health and Care Radicals one day school Bolton 26 May 2016

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

Who we are
• A small team of people within the
NHS who support improvement
and change.
• We tune into and engage with the best
change thinking and practice in healthcare and
other industries around the world and seek to
translate this learning into practical approaches to
change.
• The team has emerged through years of
supporting change in the NHS and wider health
and care systems.

Agenda
1. Being a health and care radical: change starts with
me
2. From Me to We: Forming communities and
building alliances for change
3. Rolling with resistance
4. Moving beyond the edge make change happen
5. Change Challenge unconference

How we make a difference
The School has been formally evaluated by
the Chartered Institute for Personnel
& Development
Statistically significant positive effect on EVERY
dimension of impact at both individual and
organisational level
• Change knowledge
• Sense of purpose & motivation to improve practice
• Ability to challenge the status quo
• Rocking the boat & staying in it
• Connecting with others to build support for change

Twitter
#SHCR
@School4Radicals
Facebook group
School for Health and
Care Radicals
Join in on social media

Follow us on Twitter
@School4Radicals
@KateSlater2
@OllyBenson
@JoannaHemming
@DaniG4_

Being a Health and Care Radical, what does
this really mean?

What will the future look like? But to get
here there will have to be lots of change

Kinthi Sturtevant, IBM
13th annual Change Management
Conference June 2015
We rarely see two, three or four
year change projects anymore.
Now it’s 30-60-90 day change
projects

In 2005…
• Facebook didn’t widely exist
• Twitter was still a sound
• The cloud was still in the sky
• 4G was a parking place
• LinkedIn was a prison
• Applications were what you sent to college
• Skype was a typo
16
Source: Thomas Friedman, World Economic Forum. Quoted by: http://aveletbaron.com

Our work and our care is getting more
complex

The power is changing
More than 70% of all major transformation efforts fail.
Why?
Because organizations
do not take a
consistent, holistic
approach to changing
themselves, nor do they
engage their
workforces effectively.
John Kotter

SEISMIC SHIFTS
Change from the edge

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

Adapted from 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

John Kotter, the most influential thought leader
globally, recognises new approaches are needed
FROM

John Kotter: “Accelerate!”
• We won’t create big change
through hierarchy on its own
• We need hierarchy AND network
• Many change agents, not just a
few, with many acts of leadership
• At least 50% buy-in required
• Changing our mindset
• From “have to” to “want to”
TO

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

The Network Secrets of Great Change Agents
Julie Battilana &Tiziana Casciaro
1. As a change agent, my centrality in the informal
network is more important than my position in
the formal hierarchy
2. If you want to create small scale change, work
through a cohesive network
If you want to create big change, create
bridge networks between disconnected groups

strong ties (cohesive)
v.
weak ties (disconnected)
Source of image: http://www.forbes.com/fdc/welcome_mjx.shtml

When we spread change through strong ties:
• We interact with “people like us”, with
the same life experiences, beliefs and
values
• Change is “peer to peer”; GP to GP,
social worker to social worker, nurse to
nurse, community leader to
community leader
• Influence is spread through people
who are strongly connected to each
other, like and trust each other

The pros and cons of strong ties
Pros Cons

When we seek to spread change through
weak ties
• we build bridges between groups and
individuals who were 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 can mobilise all the resources in our
organisation, system or community to help
achieve our goals

Why we need to build weak ties AS WELL AS
strong ties
• Weak ties are more likely to lead to change at scale
because they enable us to access more people with
fewer barriers
More on weak ties: https://www.youtube.com/watch?v=w7AzRVxhEXA#t=45

Why we need to build weak ties AS WELL AS
strong ties
• Weak ties are more likely to lead to change at scale
because they enable us to access more people with
fewer barriers
• In situations of uncertainty, we have a tendency to
revert to our strong tie relationships
 yet the evidence tells us that weak ties are
much more important than strong ties when it
comes to searching out resources in times of
scarcity
• The most breakthrough innovations and most
radical change will come when we tap into our weak
ties

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

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

What is a rebel?
•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

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: adapted from Debra E Meyerson

What are the risks for a boat rocker?
1. Our experiences of “being different” can be
fundamentally disempowering. This can lead us to
conform because we see no other choice
 we surrender a part of ourselves, and silence
our commitment, in order to survive
2. leave the organisation
 we cannot find a way to be true to our values
and commitments and still survive
3. stridently challenge the status quo in a manner
which is increasingly radical and self-defeating
 this just confirms what we already know – that
we don’t belong
Source: adapted from Debra E Meyerson

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

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

What led you into health?
We asked via
twitter the
question what led
you into nursing?
The responses
were around the
rebel values.

You can’t be a rebel alone
• Stay close to where you started
• Remain focused on the goal
• Understand the story
• Strengthen and widen your network and ties
• Believe in yourself
• Be not be afraid

Outcomes of randomised
coffee trials

Photo credit: Flickr / hugobernard

So how can we harness the power
of our shared humanity to help us
accomplish positive change?

#IQTGOLD Photo credit: Flickr / mikemcsharry

“Communities are characterized
by three things: common interests,
frequent interaction, and
identification.“
Wally Block

#IQTGOLD Photo credit: Flickr / geoffandsherry

“Power used to come largely
through and from big institutions.
Today power can and does come
from connected individuals in
community.”
Nilofer Merchant

“There is no power for change
greater than a community
discovering what it cares about.”
Margaret Wheatley

#IQTGOLD Photo credit: Flickr / stjc

Learning from previous social
movements

How do organisations develop
activists?

#IQTGOLD Photo credit: Flickr / Angell Williams.

#IQTGOLD Photo credit: Flickr / memespring

#IQTGOLD Photo credit: Flickr / santanuvasant

“Great social movements get
their energy by growing a
distributed leadership”
Joe Simpson

“Framing is the process by which
leaders construct, articulate and
put across their message in a
powerful and compelling way in
order to win people to their cause
and call them to action.”
Snow D A and Benford R D (1992)

#IQTGOLD
“I have some Key
Performance Indicators
for you”
“I have a dream”

“I think people have begun to forget how
powerful human stories are, exchanging their
sense of empathy for a fetishistic fascination
with data, networks, patterns and total
information.
Really, the data is just part of the story. The
human stuff is the main stuff, and the data
should enrich it.”
Jonathan Harris

#IQTGOLD
inertiaurgency
anger apathy
solidarity isolation
you can make a
difference
Self-doubt
hope fear
Overcomes
Action motivators Action inhibitors

Using stories to connect and
prompt action

“Leaders must wake people out of
inertia. They must get people
excited about something they’ve
never seen before, something that
does not yet exist.”
Rosabeth Moss Kanter

Tell a story
Make it personal.
Be authentic.
Create a sense of ‘us’ (and be clear who ‘us’ is)
Build in a call for urgent action.

Challenges and choices
• In the first sentence, make a connection with your audience.
• In the second sentence, give us the context of your story.
• In the third sentence, tell us about the challenge or crisis in your story.
• In the final sentence, provide closure to your story – tell us the outcome
of your choices.

#SCHR #Quality2015 @HelenBevan @BoelGare @jackielynton
Rolling with resistance

Image copyright: http://13c4.wordpress.com/2007/02/24/50-reasons-not-to-change/

Employee resistance is the
most common reason
executives cite for the
failure of big
organizational-change
efforts
Scott Keller and Colin Price
(2011), Beyond Performance: How
Great Organizations Build Ultimate
Competitive Advantage
Source of image:
Businessconjunctions.com

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

#SCHR #Quality2015 @HelenBevan @BoelGare @jackielyntonSource: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively

#SCHR #Quality2015 @HelenBevan @BoelGare @jackielyntonSource: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively
Make it a personal
PERFORMANCE target.

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

“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.
—

Resistant behaviour is a good
indicator of missing relevance
Harald Schirmer
http://de.slideshare.net/haraldschirmer/strategies-for-corporate-change-the-new-
role-of-hr-driving-social-adoption-and-change-in-the-enterprise
Source of image: driverlayer.com

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

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

• Designed for Stage 4 –
ACTION!
• Mandated it through
targets
• Despite compelling
case for change –
people resisted it – no
values connection
• People did the task
and missed the point
Example – WHO Surgical Safety Checklist

IN A NUTSHELL
• Evidence from observational studies that the use of surgical safety
checklists results in striking improvements in outcomes
• Led to rapid adoption of such checklists worldwide
• Researchers studied effect of mandatory adoption of checklists in
Ontario, Canada
• Use of checklists not associated with significant reductions in
operative mortality or complications

• 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 (Singh)
• Don’t argue against it
• Encourage elaboration of resistance
•What makes it so hard?
• What would help?
• Build meaning and conviction in the
change
So what SHOULD we do?

• The biggest-ever digital campaign for EMAP
(Health Service Journal and Nursing Times)
• 14,000 contributors to the joint campaign to
“challenge top down change”
• Ground-breaking: the first-ever crowd-sourced
theory of change in 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

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

If your horse dies,
get off it
Cherokee proverb
Source of image: fenwickgallery.co.uk
‘‘

Five stages of grief Kubler Ross

of change fails
Dr Peter Fuda
70%

#IQTGOLD
Doing
• Where most change agents
in health and care put most
of their effort and
emphasis
• What others typically judge
us on
• What we often perceive we
need to do to add value
• What most change and
improvement courses focus
on

#IQTGOLD
Seeing and Being
• We can only do effective
“doing” if we build on
strong foundations of
“seeing and being”
• Change begins with me
• Hopeful futures, creative
opportunities and potential
• Multiple lenses for change
• See myself in the context of
my higher purpose

Doing. Seeing. Being.
• What has been some of the key learning from
the School for Health and Care Radicals under
each category?
• How is your own current balance between
doing, seeing and being in your practice as a
change agent?
• What might you want to do differently, or
additionally in future?

Traditional conference
The agenda is pre-set
One way learning style
with Questions & Answers
People sit in rows or round
tables as prescribed
Networking between
sessions
Hard to leave the session
once it starts
Absorbing information
Unconference
People set the agenda
Based on discussion
People sit where they
want
Networking the whole
time
Encouraged to find the
right session
Connecting to action
Source: adapted from @BCPSQC

The unconference:
4 principles
Principles:
1. Whoever comes are the right people
2. Whatever happens is the only thing that could
have happened.
3. When it starts is the right time
4. When it's over it's over
The Law of Two Feet:
"If you find yourself in a situation where you are not
contributing or learning, move somewhere where
you can."

Our process
• Think about a topic that you would like to
explore with other people based on what you
have heard today
• It should be a topic that you want to take
action on over the next twelve months
• Suggest your idea to the big group

The task
• Discuss your topic and identify key actions
that should be taken
• Summarise your discussion on one sheet of
flip chart
• On a separate sheet of A4 paper write one
“big idea” for an action you can take within a
week, a month and a year
Time available: 50 minutes

Topics
• Digital communities
• Preventive health
• Mental health in physical health
• Macmillan change
• Student funding
• Leading change between community and
acute

Four ways to connect
Subscribe to theedge.nhsiq.nhs.uk
Get materials from theedge.nhsiq.nhs.uk/school
Sign up for our monthly #EdgeTalks
theedge.nhsiq.nhs.uk/edgetalks
Watch sessions from
theedge.nhsiq.nhs.uk/transformathon

School for Health and Care Radicals one day school Bolton 26 May 2016

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School for Health and Care Radicals one day school Bolton 26 May 2016

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