School for Health and Care radicals - Slides for module four

#SHCR @School4Radicals
Module 4
Making change happen
Supported by:
http://www.theedge.nhsiq.nhs.uk/school/
Module

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Joining in today…and beyond

Session lead:
Helen Bevan
@HelenBevan
Learning lead:
Pip Hardy
@PilgrimPip
Session chair:
Kate Pound
@kateslater2
Twitter & chat
monitor:
Olly Benson
@ollybenson
Storyteller:
Rebecca Lacey
@rebeccalacey76
Storyteller:
Jas Atwal
@jasjitkauratwal
Storyteller:
Joyce Lee
@joyclee
The team today

Programme Study Guide:
www.slideshare.net/TheEdgeNHS/school-
for-health-and-care-radicals-iii-study-
guide-2016?related=2
Module 4 Study Guide:
http://www.slideshare.net/TheEdgeNHS/
school-for-health-and-care-radicals-
module-4-study-guide-2016
Study guides

Modules
3rd March: Moving beyond the edge

Our growing community
• The American College of Radiology
• Macmillan nursing team growing
School news
• Twitter chat for #SHCRmh today 20.00-21.00 (GMT)
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(GMT)
• After school club north east on 7th April 1pm connect
with @markdavis272 or @maxine_craig

Icebreaker: Making change happen
Which of these are you most interested in
finding out about today?

Today
• Why change efforts often fail to achieve
their objectives
• Leading large-scale change
• Intrinsic and extrinsic motivators for
change
• Building energy for change
• Creating shared purpose
• Discussion and reflection
Sourceofimage:www.freshnessmag.com

#SHCR @School4Radicals Source of image: Whatsthebigideascwartzy.blogspot.com

Most change programmes fail to
deliver their objectives
Source: McKinsey Performance Transformation Survey, 3000 respondents to
global, multi-industry survey
70%
25%
5%
Gets anywhere near
achieving the
change and
delivering the
benefits

Source: McKinsey Performance Transformation Survey, 3000 respondents to
global, multi-industry survey
70%
25%
5% Delivers and
sustains the change
Most change programmes fail to
deliver their objectives

Source:
2016 Chartered Institute of Management Quality of Working Life study
Across the UK, poorly managed change programmes are
damaging morale and the performance of organisations

It is our contention that most change efforts are built upon
the shaky foundation of five flawed assumptions; that
change can be managed, that human beings are objective,
that there are ‘X’ steps to change, that we have a neutral
starting point for change, and that change, itself, is the goal
Peter Fuda
http://www.peterfuda.com/wp-content/themes/peterfuda-
bootstrap/content/Why-Change-Efforts-Fail.pdf
Source of image: Whatsthebigideascwartzy.blogspot.com

Change is not the goal;
the goal is the goal
Peter Fuda
Source of image:
timemanagementninja.com

@School4Radicals #SHCR
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

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

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
Buy in from front line staff is critical for
improvements in quality and safety . Don’t
overload them
Buy in from front line staff is critical
for improvements in quality and safety
Don’t overload them
http://healthaffairs.org/blog/2014/03/07/the-
dangers-of-quality-improvement-overload-insights-
from-the-field/

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

@School4Radicals #SHCR@HelenBevan #NHSelect15
Types of motivation
Source of image: http://youearnedit.com/blog/intrinsic-vs-extrinsic-motivation/

@School4Radicals #SHCR@HelenBevan #NHSelect15
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
From

Tapping into intrinsic motivation is critical
to ongoing, large scale change
So while both extrinsic and intrinsic motivation have their
place when implementing change, identifying underlying intrinsic
motivation remains the differentiating factor between long-term
success and failure. Every long-term, sustained extrinsic success
story has tapped into intrinsic motivation at its core……
While extrinsic motivation can produce some initial success on its
own, people will move on from tasks that they no longer find
personally challenging. So unless system leaders want to
continually increase the reward for the same task, they need to
find a way to appeal to user’s values…..
.
The Blog for Happy Workers: http://www.happymelly.com/why-intrinsic-motivation-is-the-key-to-change-management/
‘

Intrinsic
motivators
build energy
and creativity

Intrinsic
motivators
•connecting to
shared purpose
•engaging, mobilising and
calling to action
•motivational leadership
build energy
and creativity

Intrinsic
motivators
•connecting to
shared purpose
calling to action
build energy
and creativity create focus &
momentum for
delivery
Drivers
of extrinsic
motivation

Drivers
of extrinsic
motivation
create focus &
momentum for
delivery
Intrinsic
motivators
•connecting to
shared purpose
calling to action
build energy
and creativity
•System drivers &
incentives
•Payment by results
•Performance
management
•Measurement for
accountability

Internal
motivators
•connecting to
shared purpose
calling to action
build energy and
creativity
Drivers of
extrinsic
motivation
•System drivers &
incentives
•Performance
management
•Measurement for
accountability
create & focus
momentum for
delivery

The Change Model
Source: Zoe Lord

Priority area: Acute Kidney Injury (AKI) – NHS Kidney Care
What outcomes do we seek?
Our Shared Purpose
Is there a sense of shared
purpose amongst our key
stakeholders?
The shared purpose is to
improve the prevention,
detection and management
of AKI across the whole NHS
system
Leadership by all
Do all our leaders have the skills
to create transformational
change?
NHS Medical Director
NHS Commissioning Board
Clinical Commissioning Groups
National Clinical Lead
Royal College of Nursing
NHS Nursing Director
AKI Delivery Group
National Vascular Society for
Great Britain & Ireland
Clinical Leads
Network Leads
Patient Groups
Motivate and Mobilise
Are we engaging and mobilising
all the right people?
AKI London Network
Deaneries
Directors of Nursing
AKI Specialist Registrar Network
AKI App
Spread and Adoption
Are we designing for the active
spread of innovation?
Acute Kidney Injury Resource
Pack
Hydration Matters Campaign
AKI Audit in Acute Assessment
Units in the North East of
England
E-alerts Survey
Medicines Optimisation Toolkit
How to Guides
Project and performance
Management
Do we have an effective
approach for delivery of change
and monitoring of progress
towards our planned objectives?
Project Management Office
Risk & Issues Log
Influencing factors
Are our processes, incentives
and systems aligned to enable
change? The Burdon of AKI –
Health Economics Study
AKI Recording & Coding
AKI Consensus Conference
NICE (Guideline 50)
NCEPOD
Improvement tools
Are we using an evidence-based
quality improvement
methodology?
YES = quality improvement
Measurement
Are we measuring the outcome
of the change continuously and
transparently?
National Confidential Enquiry
into Patient Outcome and Death
AKI Markers in National Registrar
Vascular Database
Atlas of Variation

“Without using the change model to undertake a gap
analysis, we would have never have known many of our
collective strengths and our challenges which would have
had a direct impact on achieving our goal”
Beverley Matthews
http://www.londonaki.net/

“Take your
passion and
make it
happen”
Source of image: www.zeelandtheaters.nl

Two kinds of people at work
 Feel connected to a
higher purpose
 Controlled & coordinated
through shared goals &
values
 Collaborate
 Embrace change
 Work to who they are
The contributors The compliant
• Feel disconnected from
purpose
• Controlled & coordinated
through performance
management & standardised
procedures
• Hold back
• Resist change
• Work to a role specification
Adapted from The Emotional Economy http://emotionaleconomy.com.au/papers-articles/why-the-winners-in-
business-are-taking-the-time-to-build-a-positive-kind-social-culture/

Two kinds of people at work
 Feel connected to a
higher purpose
 Controlled & coordinated
through shared goals &
values
 Collaborate
 Embrace change
 Work to who they are
The contributors The compliant
• Feel disconnected from
purpose
• Controlled & coordinated
through performance
management & standardised
procedures
• Hold back
• Resist change
• Work to a role specification
Gallup global research:
• Only 13% of the workforce are
engaged (contributors)
• Contributors create six times the
value to an organisation
compared to the compliant
http://www.gallup.com/poll/165269/wor
ldwide-employees-engaged-work.aspx

Telling her story
Jas Atwal
@jasjitkauratwal

Dr Jasjit Kaur
Atwal
@jasjitkauratwal
General Practitioner on a career break.
School Governor and Code Club volunteer.
https://codewordblog.wordpress.com

We built a computer…
and it actually works!

https://scratch.mit.edu/projects/26818098/#editor
https://scratch.mit.edu/
We have been using
a language called
Scratch to teach
the children

Amanda
Coffey
@adorescienc
e
A qualified teacher, Amanda has extensive
experience volunteering in her community
and was instrumental in setting up a local
Community Forum to enable disparate
groups to work together. As a Process Co-
ordinator working for a bank’s operations
department, Amanda used her coding
experience and networking skills to move
from paper to a digital system.

Ian Williams
@
www.fetcheveryone.com
Creator of fetcheveryone.com, a free
website for runners to log their exploits
and share their passion for running.
Bought by Hearst magazine in 2007 and
now receiving 50,000 visitors per month, it
is Ian’s full time occupation. In his spare
time, he is a Parkrun event director and
Code Club volunteer.

What happens to large scale
change efforts in reality?
In order of frequency:
1. the effort effectively “runs out of energy” and
simply fades away
2. the change hits a plateau at some level and no
longer attracts new supporters
3. the change becomes reasonably well established;
several levels across the system have changed to
accommodate or support it in a sustainable way
Source: Leading Large Scale Change:
a practical guide (2011), NHS Institute

Typically, around any change effort, there is an
initial spike of tangible energy, and change, but
when leadership loses interest, the momentum
of change slows down drastically.”
Tara Paluck

Bruch and Vogel research
Organisations with HIGH productive
energy scored higher on:
 overall performance - 14% higher
 productivity – 17%
 efficiency – 14%
 customer satisfaction – 6%
 customer loyalty – 12%

Energy for change
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/energ
y_for_change/energy_for_change_.html

Psychological
Physical
Spiritual
Social Intellectual
Energy for change

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”

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

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

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

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

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

 Which group likely to have
higher spiritual energy
scores (clinicians/non
clinicians?)
 Nearer to CEO, higher or
lower energy scores?
Some questions

• Are particular
energy domains
more dominant
than others for
our team at the
moment?
• Is this the
optimal energy
profile to help
us achieve our
improvement
goals?
Energy for change profile
1
2
3
4
5
Social
Spiritual
PsychologicalPhysical
Intellectual

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

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

1
2
3
4
5
Social
Spiritual
Intellectual
Where is your team?

There has never been a time in the history
of healthcare when this advice has been
more pertinent
“Leadership is not about making clever
decisions and doing bigger deals. It is about
helping release the positive energy that
exists naturally within people”
Henry Mintzberg

Telling her story
Rebecca Lacey
@rebecccalacey76

Shared purpose aligns.....
Shared purpose allows
many communities to
engage with us without us
having to invest resources
in controlling their actions
Nilofer Merchant

 Shared purpose is a common thread in
successful change programmes*
 Organisations and change initiatives with strong
shared purpose consistently outperform those
without it.**
*What makes change successful in the NHS? Gifford et al 2012 (Roffey Park Institute)
**Management Agenda 2013 Boury et al (Roffey Park Institute)
We know that ...

A 3-word concept

[Shared] purpose goes way deeper than
vision and mission; it goes right into your gut
and taps some part of your primal self. I
believe that if you can bring people with
similar primal-purposes together and get
them all marching in the same direction,
amazing things can be achieved.
Seth Carguilo

“Matching Michigan” is a great example
of the power of shared purpose
Perhaps the single most important influence on program response by individual
units—either in promoting or resisting change—was the extent of consensus and
coalition among the senior medical and nursing staff on individual ICUs….
Transforming or boosting of efforts was most likely to occur when those locally
charged with implementation were sincere in their beliefs about the value of the
program, were able to create transdisciplinary alliances, had local credibility
among peers, were prepared to tolerate debate but exercise firmness, and used
multiple tactics including role modelling, persuasion, sanctioning, reminders, and
constant feedback….
[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.’
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3704826/

As leaders, we are “signal generators”
“As a leader, think of yourself as a “signal generator”
whose words and actions are constantly being
scrutinised and interpreted, especially by those
below you” [in the hierarchy]
“Signal generators reduce uncertainty and ambiguity
about what is important and how to act”
Charles O’Reilly,
Leaders in Difficult Times
Source of image:
vintage-radio.com

Avoiding “de facto” purpose
 What leaders pay attention to matters to staff, and consequently
staff pay attention to that too
 Shared purpose can easily be displaced by a “de facto” purpose:
 hitting a target
 reducing costs
 reducing length of stay
 eliminating waste
 completing activities within a timescale
 complying with an inspection regime
 If purpose isn’t explicit and shared, then it is very easy for
something else to become a de facto purpose in the minds of the
workforce
Source: Delivering Public Services That Work: The Vanguard Method in the Public Sector

....the last era of management was about how
much performance we could extract from
people
.....the next is all about how much humanity we
can inspire
Dov Seidman

How to make change happen
 Stop bribing
 Make people feel
something
 Emphasise progress
 Start a cult (a group
unified by a provocative
idea)
Source: How to motivate people:
four steps backed by science

Telling her story
Joyce Lee
@joyclee

http://ihavefoodallergies.tumblr.com
Patient as
Expert
Maker
Collaborator

Healthdesignby.us
Participatory Design = Maker Movement
Expert = DIY
Maker = Learning by doing
Collaborator = Peer-to-Peer

Design with and not for patients
Integrate design into your daily
workflow
User research as an educational
opportunity
Make the dream clinic happen
Design with members of a
different tribe
Identify your latent innovators

Next opportunities for learning
• Next Tuesday, 1st March
1900-2000 GMT: Tweet chat #SHCR
• Next Thursday 3rd March
1430-1600 GMT: Module 5:
Moving beyond the edge

There’s still time to take part in an RCT!
• Randomised Coffee Trial!
• Randomised Coffee Trial!
Randomised Coffee Trial!

Questions for reflection
• How can I make the most of both intrinsic and
extrinsic aspects of change?
• How can I build energy for change for the long
haul?
• How can I ensure shared purpose throughout
my change process?

• Identify three ways in which I can ignite
energy for change within my own groups and
communities.
• Consider how I will build commitment to
shared purpose in all my change efforts.
• Take one action tomorrow to accelerate
change.
Call to action

Goodbye and good luck!
‘There is a thread you
follow. It goes among
things that change. But it
doesn’t change… while
you hold it you cannot get
lost.’
William Stafford
Goodbye and good luck!

School for Health and Care radicals - Slides for module four

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