A7+B7 Christina Krause & Marlies van Dijk - Leading Large Scale Change

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


Model of Large Scale Change


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


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



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




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


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


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


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


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:


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

[email protected]

@tweetvandijk

Christina Krause

[email protected]

@ck4q

mailto:[email protected]

mailto:[email protected]

A7+B7 Christina Krause & Marlies van Dijk - Leading Large Scale Change

Documents

Transcript of A7+B7 Christina Krause & Marlies van Dijk - Leading Large Scale Change