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How to create change that sticks and spreads

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Helen Bevan's slides from 19th October

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How to create change that sticks and spreads

  1. 1. @HelenBevan Helen Bevan
  2. 2. @HelenBevan Some definitions Diffusion: "the process in which an innovation is communicated through certain channels over time among the members of a social system” Rogers 1962 Spread: “deliberate efforts to increase the impact of innovations successfully tested in pilot or experimental projects so as to benefit more people and to foster policy and program development on a lasting basis” Norton and colleagues 2012 Going to scale (or scale up): “at least 60% of the target population that could potentially benefit from the programme receives it” Rabin and colleagues (2012)
  3. 3. @HelenBevan How do we measure success? “Unless a program can be replicated and sustained on a large scale, it will not be transformational….. We can no longer evaluate programs simply based on how well they’ve performed in a given locality. Instead, we need to factor in their potential to achieve scale” McKinsey on Society
  4. 4. @HelenBevan From 2001 to 2005, I was responsible for the Research into Practice team within the NHS Modernisation Agency The team role was to promote the spread and sustainability of service improvement and helped to build a body of knowledge We found that the factors of sustainability are also the factors for effective spread Spread and sustainability
  5. 5. @HelenBevan We have more than 20 years experience of spreading large scale change “It has been positively reviewed and reported in the nursing & healthcare press and its implementation is proven to produce significant savings in productivity & efficiency” White et al 2013 One of the most widely adopted and impactful improvement programmes in the history of the NHS; “releasing time to care”, typically 10-20% of the time of clinical professionals. The changes were adopted by 78% of NHS hospital wards, 68% of mental health wards, 54% of NHS operating theatres and 49% of community health teams across England (SHA statistics) as well as 44 territories across the globe New Zealand: 19% of time“ released to care” Oregon USA: multi-factorial improvements Scotland: “20% of time released to care” A significant, positive impact on staff engagement Irish research: the effects were sustained over time 800,000 pledges; engaged two thirds of all NHS organisations Our most successful ever digital campaign
  6. 6. @HelenBevan Source: The “classic” approach to spread – the jury is out!
  7. 7. @HelenBevan Because the reality is often different
  8. 8. @HelenBevan Enthusiasts Visionaries Pragmatists Conservatives Laggards Source: Geoffrey Moore, building on the work of Everett Rodgers Beware the chasm The typical effect sizes of spread activities are perhaps 10-20% at best (Grimshaw)
  9. 9. @HelenBevan Emerging themes in spread • Increasing attention to the demand side, to better understand the adopter’s point of view • Coalition building (social movements and social media) • Increasing attention to system conditions • Acknowledgement of context sensitivity • The importance of co-design for subsequent scaling Source: David Albury
  10. 10. @HelenBevan Nine repeating patterns from pilot programmes #1 Promising pilot programmes are rarely replicated successfully from pilot localities to others; the wider and more complex the change, (i.e., involving multiple organisations) the least likely that spread will happen
  11. 11. @HelenBevan Kaiser Permanente spread model Just do it Innovate Test and replicate CLEAR COMPLEX CHAOTIC COMPLICATED Source: Schall and Schilling
  12. 12. @HelenBevan #2 Most of the early effort and energy is needed to make the pilot programme functional and issues of spread & scale often end up being an afterthought Nine repeating patterns from pilot programmes
  13. 13. @HelenBevan #3 We typically focus on extrinsic motivators to change, rather than intrinsic & we don’t align the motivators; as a result, change is often experienced by people at the front line as “have to” (imposed) rather than “want to” (embraced) Nine repeating patterns from pilot programmes
  14. 14. @HelenBevan Intrinsic motivation People engage in the activity for the pleasure and satisfaction of doing it Invokes many positive behaviours Extrinsic motivation People engage in the activity for the rewards or avoiding punishment Any external influence is referred to as extrinsic motivation Images:
  15. 15. @HelenBevan The power of extrinsic drivers
  16. 16. @HelenBevan Three types of levers for large scale change ‘Prod mechanisms’ targets performance management price & payment incentives regulation competition ‘Proactive support’ relies on building ‘intrinsic motivation’ in staff to make the right changes to improve ‘People focused’ education and training national contracts professional regulation clinical quality standards Type one: Type two: Type three: Source: Health Foundation report Constructive comfort: accelerating change in the NHS 2015
  17. 17. @HelenBevan Three types of levers for large scale change ‘Prod mechanisms’ targets performance management price & payment incentives regulation competition ‘Proactive support’ relies on building ‘intrinsic motivation’ in staff to make the right changes to improve ‘People focused’ education and training national contracts professional regulation clinical quality standards Type one: Type two: Type three: Source: Health Foundation report Constructive comfort: accelerating change in the NHS 2015 Less than 10% of the potential for improvement at system level can be delivered through type one change Claire Alcock
  18. 18. @HelenBevan #4 People outside of pilot locality don’t feel any ownership of, or emotional connection with, the pilot project. As a result, the change processes can end up being “pushed” onto other localities rather than “pulled” by them Nine repeating patterns from pilot programmes
  19. 19. @HelenBevan Closed innovation Open innovation As a pilot test site , we want to be left alone for a period of time so we can work it out for ourselves As a pilot test site, we seek to continuously get ideas and guidance from leading thinkers and practitioners outside our local area We will test our new ways of working internally “to destruction”. When we are confident they will work, we will offer to share our “best practice innovations” with others A wider group has contributed to the innovation process, beyond our host organisation; people from other localities already feel that they own it. Spread is more likely to be “done with” not “done to” and to be “pulled” not “pushed”
  20. 20. @HelenBevan The power of co-creation
  21. 21. @HelenBevan Open innovation is a mindset, not just a process We would love to share with others but there don’t seem to be any takers
  22. 22. @HelenBevan #5 Even where we are able to create replicable change concepts from the pioneering localities, if we don’t have an implementation approach for spread that engages different local contexts, it doesn’t work Nine repeating patterns from pilot programmes
  23. 23. @HelenBevan Innovations won’t put down roots if the ground isn’t fertile Source: David Fillingam • National and regionally led improvement initiatives have their place • But “ sheep dipping” managers and clinical leaders in programmes external to their local communities is unlikely to have lasting benefit • What’s more the learning won’t spread to other communities (or even be sustained in its place of origin) unless each community has its own locally developed and owned culture and system of improvement
  24. 24. @HelenBevan There is a tendency towards “cargo cult” improvement Attempts are made to spread/replicate new models from pilot projects without a proper understanding of how they work. They end up reproducing the superficial outer appearance but not the mechanisms that produced the outcomes in the first instance (Dixon-Woods & colleagues 2011) Cargo cult
  25. 25. @HelenBevan What is the best way to spread new knowledge? Source of data: Nick Milton /why-knowledge-transfer- through.html Social connection/discussion is 14 times more effective than written word/best practice databases/toolkits etc. Source of image:
  26. 26. @HelenBevan #6 The pioneer localities have limited bandwidth to coach others & spread best practices Nine repeating patterns from pilot programmes
  27. 27. @HelenBevan #7 Local leaders are understandably much more concerned with local change than they are with spread Leaders of the macro level system must act as catalysts for spread Nine repeating patterns from pioneer/pilot type programmes
  28. 28. @HelenBevan “Choreographers of complexity” Scale up efforts should be overseen by a “choreographer of complexity”: “An analogy can be made to the role a choreographer takes in a dance company. Their job is to produce a finished work that integrates many different performance elements; music, dance, and storytelling. This must be done by making trade offs and finding synergies within the available resources of the [organisation or system], and all the while driving toward an ultimate vision.” McClure and Gray (2015b)
  29. 29. @HelenBevan #8 The commitment, characteristics & skills of local clinical leaders is often the crux issue for change in specific settings Nine repeating patterns from pilot programmes
  30. 30. @HelenBevan “Perhaps the single most important influence on programme response by individual units—either in promoting or resisting change—was the extent of consensus and coalition among the senior medical and nursing staff…. [Consultant says] ‘I think it’s been successful because it’s a unifying program, it’s one of the few things that we’ve done that hasn’t been just a doctor thing, or just a nurse thing, it’s involved the doctors and the nurses together.’”
  31. 31. @HelenBevan #9 Sustainability of change is as much of a challenge as spread of change. The same receptive local contexts create the conditions for both spread and sustainability (See Buchanan and colleagues) Nine repeating patterns from pilot programmes
  32. 32. @HelenBevan Few evaluative studies look beyond the pioneers to the issues of scale & spread so empirical evidence is limited
  33. 33. @HelenBevan The Change Challenge Tapping the collective brilliance of the NHS
  34. 34. @HelenBevan What does the NHS workforce think? 14,000 contributors recently 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
  35. 35. @HelenBevan What does the NHS workforce think? 14,000 contributors recently 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
  36. 36. @HelenBevan Project Aristotle: analysis-google-discovers-the-key-to-good-teamwork-is-being-nice/ After years of intensive analysis, Google discovers that the key to high performing, teams that deliver change is psychological safety
  37. 37. @HelenBevan Ideas and new ways of working get spread when there is: a critical problem that the innovation is addressing OR a major opportunity that it is realising wide engagement in the design and development of the innovation (involving potential adopters right from the start) strong evidence of: • desirability (relative advantage) and • feasibility (ease of integration into current working practices and systems, and/or adaptability to local context) and • viability (compelling business case) priority above other innovations, either by having an influential champion(s) or ‘top down’ (senior leader-led) Harnessing of professional networks an approach that doesn’t focus purely on WHAT we do in terms of scaling, but the WAY that we do it. Source: David Albury
  38. 38. @HelenBevan What do the leaders who get the best spread results do? They: Source: McCannon • Attempt remarkable things (provocation and optimism) • Talk about justice • Have a shared story • Apply many levers • Play jazz (adaptive, creative) • Keep it simple (e.g., interventions, measurement systems) • Model trust • Seek affection and give recognition • Break rules (avoid consensus, condense timescales)
  39. 39. @HelenBevan The conclusions of the very first national spread programme in the NHS (National Booked Admissions programme from 1998) are still highly relevant This evaluation has shown that there are no magic bullet solutions….The main source of change and service improvement has to come from within each and every NHS organisation. Renewed effort now needs to be put into developing the staff and organisations that can embrace the kind of cultural change foreshadowed by the NHS Plan. No amount of guidance, support, hectoring or cajoling can substitute for the lack of capability and understanding among the staff delivering care to patients of the need to reshape the provision of services. Chris Ham & colleagues, 2002
  40. 40. @HelenBevan References • Barker P, Reid A, Schall M (2016) A framework for scaling up health interventions: Lessons from large- scale improvement initiatives in Africa Implementation Science • Buchanan D et al (2007) The sustainability and spread of organizational change: modernizing healthcare • Clay-Williams R et al (2014) Do large-scale hospital- and system-wide interventions improve patient outcomes: a systematic review BMC Health Services Research • De Silva D (2014) Spreading improvement ideas: tips from empirical research The Health Foundation • Gartner (2014) The Gartner hype cycle • Greenhalgh T et al (2004) Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations Milbank Quarterly • Grimshaw J et al (2012), Knowledge translation of research findings Implementation Science • Kastelle T (2016) We’ve hit peak innovation (hype) • McClure D & Gray I (2015a) Scaling: Innovation’s Missing Middle • McClure D & Gray I (2015b) Managing the journey to scale up innovation in the humanitarian and development sector • NHS Institute for Innovation and Improvement (2012) The spread and adoption tool • McCannon J (2011) The spread problem • Moore G (2015) Crossing the chasm: marketing and selling products to mainstream customers • Norton W et al (2012) A stakeholder-driven agenda for advancing the science and practice of scale- up and spread in health • Perla R et al (April 2015) Health Care Reform And The Trap Of The “Iron Law” Health Affairs blog • Randall S (2015) Using communications approaches to spread improvement The Health Foundation • Schall M & Schilling L (2014) An introduction to spreading effective practices and From sustainability to spread and scale up
  41. 41. @HelenBevan Today in England is
  42. 42. @HelenBevan For our break, we will have a RCT
  43. 43. @HelenBevan • Randomised Coffee Trial! • Randomised Coffee Trial! Randomised Coffee Trial!
  44. 44. @HelenBevan or google “Fab stuff RCT”
  45. 45. @HelenBevan Outcomes of Randomised Coffee Trials
  46. 46. @HelenBevan Join in one of our national Randomised Coffee Trials 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
  47. 47. @HelenBevan Sign up for action with the Fab Change Day app