Background slides from a conversation about change management that I had with an exciting group of master's students studying Public Health with a focus on Health Economics, Policy, and Management at the Karolinska Institutet, Stockholm, Sweden on May 14, 2013. Contact: Carl.Savage@ki.se at the Medical Management Centre, Karolinska Institutet.

1. 2013 05 14
carl.savage@ki.se
get used to it.change.

2. SETTING THE STAGE…
1. what’s the use of theory?
2. why do science?
3. why use methods?

3. Your mission:
Become a health care quality improvement leader.

4. The challenge: ”Get MD’s to use EBM protocols”
Pay-for-performance Analyze dissemination process
Workshops to motivate quality Continuous feedback
Educate the staff in use of
guidelines
Understand MD’s situation and
change their perceptions
Talk with physicians Change medical education
Identify opinion leaders Include in licensing

5. Content
Process
Context
• Change managers
• Models of change
• Formulation/implementation
• Pattern through time
• Assessment and choice of products
and markets
• Objectives and assumptions
• Targets and evaluation
Internal
• Resources
• Capabilities
• Culture
• Politics
External
• Economic/Business
• Political
• Social
(Pettigrew & Whipp, 1993)
Essential ingredients of change

7. What AND how, not just what!
”…any transformation
journey requires
innovation both
in what you do and
in how you do it.”
(Nayar, 2010)

8. 1. Why?
2. How?
3. What
(Sinek, 2011)

9. Some current change scenarios
What is your strategy?
1. Launch a stop smoking campaign at work.
2. Set up a meeting time with a group of 4-5 busy
professionals.
3. Convince a primary care clinic to measure patient
outcomes.
4. Implement process improvement in a hospital (IHC).

10. Reflect on your change strategies
• What are the similarities and differences between
your change strategies?
• Why do you think your strategies would work?
• What assumptions have you made?
• How have you addressed those assumptions?

11. 1. Why?
2. How?
3. What
(Sinek, 2011)

12. ASSUMPTIONS
Power and the people

13. ASSUMPTION 1.
change is hard
because of resistance to change

14. 30%
(Kotter, 1995)
(McKinsey, 2008)

15. (Rogers, 1962)
(Gladwell, 2005)

16. (Rogers, 1962)

17. ASSUMPTION 2.
motivation

18. MONEY.
it’s the most expensive way to motivate people

19. THE CASE OF X & Y
Y: ”I could use your help…”

20. Motivation 2.0
Theory X
• Dislike working.
• Avoid responsibility and need
to be directed.
• Have to be controlled, forced,
and threatened to deliver
what's needed.
• Need to be supervised at
every step, with controls put in
place.
• Need to be enticed to produce
results; otherwise they have
no ambition or incentive to
work.
Theory Y
• Take responsibility and are
motivated to fulfill the goals
they are given.
• Seek and accept
responsibility and do not
need much direction.
• Consider work as a natural
part of life and solve work
problems imaginatively.
(McGregor, 1960)

21. Motivation 3.0
• Purpose
– Is my work meaningful?
• Autonomy
– Do I have the freedom to
do my work?
• Mastery
– Do I have the
opportunity to become
better and better at
what I do?
(Pink, 2006)

22. ASSUMPTION 3.
the path of change is linear

29. Unfreeze
• Awareness of
shortcomings
• Uncertainty leads
to motivation to
change
Move
• Search for
knowledge and
new examples
(Re)Freeze
• New identity
• New structures
(Lewin, 1951)
carl.savage@ki.se

30. Conventional Wisdom on Change
Kotter
1. Establish a sense of urgency
2. Create the guiding coalition
3. Develop a vision and strategy
4. Communicate the change
vision
5. Empower broad-based action
6. Generate short-term wins
7. Consolidate gains and
produce more change
8. Anchor new approaches in the
culture
Modern Management Principles
 Standardization
 Specialization
 Goal alignment
 Hierarchy
 Planning and control
 Extrinsic rewards
carl.savage@ki.se
(Kotter, 1996)
(Hamel, 2007)
2011-09-01

34. ”pilot error”
”too much airplane for one man to fly”

35. Problem with Conventional Wisdom
Identify a
problem
Call in the
experts
Design
the
perfect
solution
”Whoops”
carl.savage@ki.se
”Deficit-based solution-focused change”
2011-09-01

36. SO, WHY DO WE GET ”WHOOPS”?

37. How did we get into this mess?
Stress
Look to
authority
Pressure on
authority to
”do
something”
Temptation
for a
”quick fix”
(Heifetz, 1994)

38. Stress
Look to
authority
Pressure on
authority to
”do
something”
Temptation
for a
”quick fix”
= A leadership challenge
(Heifetz, 1994)

39. ASSUMPTION 4.
we need to lead change by pushing* change
*communicating

40. Simple
Complex
Complicated
Chaos
Certainty
Agreement
Close to
Closeto
Far from
Farfrom
(Adapted from Stacey, 1996)
Complicated
Where we act like we are
Where we actually are

41. (Glouberman & Zimmerman, 2002)

42. What’s the [type of] problem?
Situation
Problem
definition
Solution and
implementation
Primary locus of
responsibility for
the work
Kind of work
Type I Clear Clear Physician Technical
Type II Clear Requires learning
Physician and
patient
Technical and
adaptive
Type III
Requires
learning
Requires learning
Patient >
physician
Adaptive
(Heifetz, 1994)

43. Adaptive leadership
1. Get on the balcony
a) Identify the adaptive challenge
b) Regulate distress
c) Direct disciplined attention to the issues (not stress reducing distractions)
d) Give work back to the people, at a rate they can stand
e) Protect voices of leadership without authority
2. Distinguish self from role
3. Externalize the conflict
4. Use partners
5. Listen, using oneself as data; live with doubt
6. Find a sanctuary
7. Preserve a sense of purpose (Heifetz, 1994)

44. Creative tension
[What is]
[What could be…]
Where is the tension?

45. Change management
• The Path
– Shape the path
• The Rider
– Direct the rider
• The Elephant
– Motivate the elephant
(Switch, by Heath & Heath, 2010)

46. If you don’t plan on improving things,
don’tbother.

47. CHANGE IS PERSONAL:
IMPROVEMENT IS
YOUR
RESPONSIBILITY
carl.savage@ki.se
Medical Management Centre, KI