Post on 22-Jan-2015
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LEADING LARGE SCALE CHANGE
Marlies van Dijk & Christina Krause Quality Forum 2013
What will you walk away with?
• Fundamental elements that define large scale change
• Overall framework for large scale change
• Key practical tools and strategies to support you in your change efforts.
• Hopefully get you to try some of these when you get back home!
Question for Reflection
“When have you felt most energize and passionate about the work you have been
involved in?”
1. What were its features?
2. How would you describe it?
Large Scale Change – What is it and What is it not?
Incremental Change
– Process improvement
– Relatively constant shape of a flowing river
Large-Scale Change
– Transformational, qualitatively different changes
– Damming a river or altering its course
Source: P. Plsek. Creating Large Scale Change in Health Care. 2011
Three Core Elements
1. Structure
2. Process
3. Patterns of Behaviour
Structures only (no process or behaviour)
Process only (no structure or behaviour)
Behaviour only (no structure or process)
What happens when …
What is your current challenge?
1. Describe your challenge
2. What is the future state you are hoping to achieve
3. Describe who you are working with …
4. What are the challenges?
© NHS Institute for Innovation and Improvement, 2012
Large-scale change (LSC) is the emergent process
of moving a large collection of individuals, groups,
and organisations toward a vision of a
fundamentally new future state, by means of high-
leverage key themes, distributed leadership,
massive and active engagement of stakeholders,
and mutually-reinforcing changes in multiple
systems and processes, leading to such deep
changes in attitudes, beliefs, and behaviours that
sustainability becomes largely inherent.
Large-scale change (LSC) is the emergent process
of moving a large collection of individuals, groups,
and organisations toward a vision of a
fundamentally new future state, by means of high-
leverage key themes, distributed leadership,
massive and active engagement of stakeholders,
and mutually-reinforcing changes in multiple
systems and processes, leading to such deep
changes in attitudes, beliefs, and behaviours that
sustainability becomes largely inherent.
A working definition
Large Scale Change
© NHS Institute for Innovation and Improvement, 2012
Model of Large Scale Change
© NHS Institute for Innovation and Improvement, 2012
Summarising the key differences in the approach to large scale change and “normal” change
Normal Change Large Scale Change
Credible ambition
defined future state
clear organisation scope
agreed leaders throughout
processes or systems or behaviours
strong programme management
controlled through hierarchy
compliance led*
Incredible ambition
managing an emergent final state
multiple organisations and partnerships
distributed and changing leadership
processes and systems and behaviours
programme management and social movement
managed through influencing and engagement
commitment led
Differences
*Compliance can lead to commitment for some
© NHS Institute for Innovation and Improvement, 2012
Similarities
Normal Change and LSC
Working to an inspiring vision
Use best practice improvement tools
Require great leadership
Require effective team working
Urgency for delivery
Summarising the key similarities in the approach large scale change and “normal” change
Overcoming the Challenges …
They get designed using the same mindset, belief and rules as have been used before ….
Building advanced improvement capability for BC
Another view: Quality of …
Level One: doing
(processes)
Level Two: thinking/
decision making
Level Three: information that
influences thinking
Level Four: information that influences
behavior
Level Five: relationships (information flow)
Level Six: perceptions and feelings (culture)
Level Seven: individuals mind-sets (personal beliefs and values)
“Engine” of quality
D. Balestracci. Data Sanity. 2009
“Fuel” of quality
Another View:
Quality of …
Our Example: Culture
Complex Adaptive Systems
Complex adaptive systems are composed of many interdependent, heterogeneous parts that self organize and co-evolve.
Unpredictable
(Camazine, 2001; Kauffman, 1995; Allen & Varga, 2006)
Why is change so hard in health care?
• Pilot projects generally do well
• Spreading throughout our system has proven to be difficulty
• Often attributed to variation at a local level
Self-Organization
Self-organization is a process whereby local interactions give rise to patterns of organizing.
ADAPTIVE – RESILIENT – UNCERTAIN
(and difficult to manage)
H.J. Lanham et al., How complexity science can inform scale-up and spread in health care:
Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)
Interdependencies Overarching term for relationships, connections, and interactions among parts of a complex system.
Pre-Intervention Post-Intervention
Lindberg, C., & Clancy, T. R. (2010). Journal of Nursing Administration
Sense Making
So now what? How do we lead in a complex system…
Acknowledge Unpredictability
• Allow design to be tailored to local contexts
• Emphasize discovery in each intervention setting
Recognize Self-Organization
• Develop “good enough”
• Facilitate sense-making
H.J. Lanham et al., How complexity science can inform scale-up and spread in health care:
Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)
So now what? How do we lead in a complex system…
Facilitate Interdependencies
• Reinforce existing relationships when effective or foster new ones
• Encourage sense-making
Encourage Experimentation
• Encourage participants to ask questions, admit ignorance and deal with paradox
• Seek out different points of view
H.J. Lanham et al., How complexity science can inform scale-up and spread in health care:
Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)
© NHS Institute for Innovation and Improvement, 2012
Your teams (and organisations) will need to manage
a number of polarities (competing tensions)
Polarity 1 Polarity 2
detailed planning emergence
central control / direction distributed leadership
evolutionary change revolutionary change
holding to account encouraging risk taking
logic to motivate change emotion to motivate change
measurement / evidence faith / intuition
Mindset Shift
From …. “current mindset”
‒ Hierarchy – I don’t question those above me
‒ Professional silos
‒ Complications (e.g., infections) are part of our business
‒ Partners must comply with what we tell them to do
To … “future mindset”
‒ No infection is acceptable
‒ I can speak up when I have concerns
‒ Patients are equal partners
‒ We work in teams
Change the Way You Change Minds
Direct Experience
Vicarious Experience
Verbal Persuasion Low
High
Mindset Shift
From …. “current mindset”
To … “future mindset”
Overcoming the Challenges
Five Organizing Practices
Disorganization Leadership Organization
Passive Shared story (public narrative)
Motivated
Divided Relationship Commitment
United
Drift Clear Structure Purposeful
Reactive Creative Strategy Initiative
Inaction Effective Action Change
Source: Helen Bevan, 2011
How do we create change at scale?
Source: Marshall Ganz and Helen Bevan
Shared understanding leads to
Action
Narrative
why?
Strategy
what?
Not all emotions are equal …
• Some motivate and some inhibit action
• Frame to overcome the inhibitor emotions (action inhibitors)
Values to Action
You can make a difference
Solidarity
Hope
Anger
UrgencyInertia
Apathy
Fear
Self-doubt
Isolation
Source: Helen Bevan, 2011
Organizational Energy …
“Extent to which the leaders of an organisation (or division or team) has mobilized its emotional, cognitive and behaviour potential to pursue its goals.”
Bruch & Vogel (2011). Fully charged: how great leaders boost their
organisation’s energy and ignite high performance.
Attributes of organizational energy:
1. Organizations activated emotional, cognitive and behavioural potential
2. Collective attribute – shared human potential of a unit or team
3. Malleable
Energy Matrix
Corrosive Energy Productive Energy
Resigned Inertia Comfortable
Energy
High
Intensity
Low
Negative Quality Positive
Heike Bruch & Bernd Vogel (2011)
“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
“There has never been a time in the history of healthcare when this perspective has been more pertinent”
Helen Bevan
“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
Move two steps down…
However long you think it is going to take to do something… move two steps down
Source: Paul Plsek
• Years
• Months
• Weeks
• Days
• Hours
• Minutes
Framing
Turning an opportunity into action …
Picture frames – what is in it you see, what is outside you do not
Provide shape and structure for organising ideas and arguments
‘Hooks’ for pulling people in
‘Springboards’ for mobilising support
Need to be authentic and connect with an individual’s reality
Target audience
Doctors
Nurses
Administration
The Public
Bad framing?
The ministry has asked us to seriously improve efficiency of cases.
The doctors would like to start on time and operate on more patients.
The ministry has mandated we increase efficiency. This is an important aspect of patient access.
We can’t control everything – surgery is complex and we can’t promise wait times or guarantee of surgery on that day.
Good framing?
Starting on time will hopefully result in completing all cases slated for the day.
How can we have a better run operating room theatre? This way we also don’t have to tell patients they have been cancelled that day.
If we have more efficient operating rooms we will be able to do more cases and control or reduce the wait lists
Help us, help you
Framing: Operation Room - Efficiency
Our aspiration is to have a healthcare system with:
• no needless death or disease
• no needless pain
• no unwanted delay
• no feelings of helplessness (for patients or staff)
• no waste
• and no inequality in service delivery
Adapted from: Don Berwick by Pursuing Perfection)
Call to Action
To enable others to achieve a common purpose through shared values and commitment and by doing this, create 'contagious commitment' to
deliver results in challenging times.
NHS Institute for Innovation & Improvement, 2012
DISTRIBUTED LEADERSHIP: BC Sepsis Network Leaders
Co-Creating Creating the Call to Action
www.worldsepsisday.org
Sept 13 - World Sepsis Day
• Strong ties vs weak ties (social network theory)
• When we spread change through strong ties …
– Interact with “people like us” with the same experiences, beliefs and values
– Change is peer to peer (e.g., nurse to nurse, GP to GP)
– Influence is spread through people who are strongly connected to each others, who like and generally respect each other
– It works because people are far more likely to be influenced to adopt new behaviors or ways of working from those they are most strongly tied
Source: Helen Bevan, 2011
Power of Networks
Strong Ties – Group Exercise
Advantages of Strong Ties
Disadvantages of Strong Ties
What About “Weak Ties”?
When we seek to spread change through weak ties:
– We build bridges between groups and individuals who are 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 mobilize all the resources in our system
We need BOTH strong and weak ties …
• Weak ties enable change at scale because they enable us to access more people with fewer barriers
• In situations with uncertainty, we gravitate to our strong tie relationships
– evidence shows that weak ties are much more important than strong ties
• More breakthroughs in innovation occur when we tap into weak ties
• The greatest opportunity we likely have for large scale improvement and change is through weak ties
• When framing your story – consider BOTH strong and weak ties
Source: Helen Bevan, 2011
Vancouver General Hospital, Kelowna General Hospital, Joseph Brant Memorial Hospital, Trillium Health Centre, Toronto East General Hospital
Dr. Michael Gardam, Principal Investigator
18 month study
• 5 self-selected hospitals
• Used Positive Deviance and Liberating Structures
– 4 used it on specific nursing units
– 1 used it hospital wide
• Measures
– Interconnectivity
– Behavioral changes
– MRSA, VRE, C. difficile rates
1
Who do you talk to today about superbugs?
Registered Nurse
Director
DES
Clerk III Support
Allied Health
Clinical Care Leader
Administration
Engineering
Professional Practise Educator
Physician
Manager Occ. Health
Volunteer
Manager
Surgical Flow Specialist
Infection Control Professional
Today, who do you talk to aboutthe prevention of superbugs (MRSA, VRE, C. difficile)?
Allied Health
Registered Nurse
Clerk
Clinical CareLeader
Director
ProfessionalPracticeEducator
Senior Administration
Infection Control Professional
Distribution andEnvironmentalSerivces
Manager
Coordinator
Pharmacist
Hospital WideStaff
Registered Practical Nurse
Physician
Talk to Today – Round 2
Laboratory Technologist
Interviews: Identified Tensions
Traditional Healthcare
Culture
Emergent Culture
In a ‘do-er’ culture, need to get
things done immediately
Taking the time for discovery
and learning
Evidence-based practice
(scientific proof)
Practice-based evidence (social
proof)
Information and data are
trusted
Stories and relationships are
trusted
Culture change is complicated Changes can be simple
Leaders need to ‘step-up’ Leaders need to ‘step-back’
Top-down leadership from
traditional leaders Bottom-up leadership from the
front line
Driver Diagrams
Primary
DriversOutcome
Secondary
Drivers
Process
Changes
Aim: An
improved
system
P. Driver
S. Driver 1Change 1
P. Driver
S. Driver 2
S. Driver 3
S. Driver 1
S. Driver 2
Change 2
Change 3
Cause Effect Drives
© Richard Scoville & I.H.I.
What Changes Can We Make? A Theory of How to Improve a System
What Changes Can We Make?
Primary Drivers
System components which will contribute to moving the primary outcome
Secondary Drivers
Elements of the associated primary driver. They can be used to create projects or a change package that will affect the primary drivers.
Primary
DriversOutcome
Secondary
Drivers
Ideas for Process
Changes
AIM:
A New
ME!
Calories In
Limit daily
intake
Track
Calories
Calories
Out
Substitute
low calorie
foods
Avoid
alcohol
Work out 5
days
Bike to
work
Plan
Meals
Drink H2O
Not Soda
drives
drives
drives
drives
drives
drives
drives
drives
Exercise
Fidgiting
Hacky
Sack in
office
What Changes Can We Make? Understanding the System for Weight Loss
“Every system is perfectly designed to
achieve the results that it gets”
© Richard Scoville & I.H.I.
Primary
DriversOutcome
Secondary
Drivers
Ideas for Process
Changes
AIM:
A New
ME!
Calories In
Limit daily
intake
Track
Calories
Calories
Out
Substitute
low calorie
foods
Avoid
alcohol
Work out 5
days
Bike to
work
Plan
Meals
Drink H2O
Not Soda
drives
drives
drives
drives
drives
drives
drives
drives
• Weight
• BMI
• Body Fat
• Waist size
• Daily calorie
count
• Exercise
calorie count
• Days between
workouts
• Avg drinks/
week
• Running
calorie total
• % of
opportunities
used
• Sodas/
week
• Meals off-
plan/week
• Avg cal/day
Exercise
Fidgiting
Hacky
Sack in
office
Percent of days
on bike
Etc...
How Will We Know We Are Improving? Understanding the System for Weight Loss with Measures
Measures let us • Monitor progress in improving
the system • Identify effective changes
Improve the Quality of
Surgical Care in BC
Skill Building
Face to Face Sessions
Site Visits
Distributed Leadership
Data
Multidisciplinary Partnerships
Patient Perspective
Clinical Leadership
Culture Survey
Teamwork + Communication
OR Team Training
Site level/ Regional events or Visits
Frontline Providers
Clinicians, Nurses, Administrators, BCMA, BCAS,
CRNBC
Local Risk Adjusted Model
Support how to share data
Patient Voice (video)
Physician Meeting
Quality Improvement
Cohesive Group – Tie in Efficiency Ministry + Board
Influence/support
Collaborative Sharing and Learning
Use clinical leaders to engage others
Principles: • Focus on Small Victories • Network Approach • Relationship Building • Transparency • Existing Communication
Channels • Raise Profile/Communicate
Values
2013/14 Goals: • Improved shift in SARs • Improved shift in Culture
Surveys • Engaged Surgeon
Champions increases from 10 to 20
• Network members increases from 555 to 800
Patients on Planning Group
From............
Compliance
States a minimum performance
standard that everyone must achieve
Uses hierarchy, systems and standard
procedures for co-ordination and
control
Threat of penalties/sanctions/shame
creates momentum for delivery
Based on organisational accountability
(“if I don't deliver this, I fail to meet my
performance objectives”)
........To
Commitment
States a collective improvement goal
that everyone can aspire to
Based on shared goals, values and
sense of purpose for co-ordination and
control
Commitment to a common purpose
creates energy for delivery
Based on relational commitment (“If I
don’t deliver this, I let the group or
community and its purpose down”)
The new era requires a shift in thinking
Source: Helen Bevan
Jayne Paulson was the Queen of
Clean
Building Commitment and Connection
Key Players No
Commitment
Let It Happen Help It Happen Make It
Happen
Unit Clerks X O
Administration X O
QI X O
etc XO
etc X O
etc XO
Three Strategies: 1. Mobilizing narratives 2. Authentic Voices (e.g., Patients for Patient Safety Canada) 3. Hot-housing (e.g., energizing meetings and events out of usual
environment)
The Value of Commitments
• We commit to specific actions that are measurable – not vague promises
– not just outcomes
• Make commitments as simple as possible (“one specific action”)
• We want to hold people to account to the things that they commit to
• When we do it effectively, commitment is much more effective than compliance
• A definite “no” is always better than a wishy-washy “yes” or “maybe”
Source: NHS Institute for Innovation and Improvement, 2011
© NHS Institute for Innovation and Improvement, 2011
Act – assignment three: commitment chart
Commitments we make
(actions not outcomes)
GETS
Commitments we ask others to make Who What By when
Executive name: _____________________________
Executive signature: ___________________________
Trust name:
© NHS Institute for Innovation and Improvement, 2012
Creating
distributed
leaders
Enrolling
Capability
building
Enabling /
removing barriers
Coaching / role
modelling
Connecting Aligning
them
Spotting
Coordinating
/ letting go
Supporting
them
Questions?
Marlies van Dijk
mvandijk@bcpsqc.ca
@tweetvandijk
Christina Krause
ckrause@bcpsqc.ca
@ck4q