Rewriting the Rules: Enduring and Emerging Approaches to Change
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Transcript of Rewriting the Rules: Enduring and Emerging Approaches to Change
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Rewriting the Rules: Enduring and
Emerging Approaches to Change
Helen Bevan
@HelenBevan
#RTR2016
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1. Identify major themes and trends in the global world of change that are starting to shake our world of healthcare improvement2. Consider the implications for our own practice as leaders and practitioners of change and improvement3. Test out some of the new change methods and approaches in an interactive way4. Consider the opportunities and implications of these for our own practice as leaders of healthcare improvement5. Take home a toolkit of new and additional approaches to supporting change to complement your existing healthcare improvement toolkit and make your improvement efforts more likely to succeed
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• Welcome and introductions; outline of the day• What’s our message for today?• What is happening in the wider world of change?• Why this is the era of the healthcare rebel• Coffee break in the form of a RCT (randomised coffee trial)• Change starts with me• Lunch• Rolling with resistance to change• Leading change in a complex world: managing polarities
(including coffee)• Sharing lessons learnt
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What is your slogan for today?
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“New truths begin as heresies” (Huxley, defending Darwin’s theory of natural selection)
Source of image: installation by the artist Adam Katzwww.thisiscolossal.com
Via @NeilPerkin
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What are the big themes for change in the world in which we now operate?
“Linear thinking does not prepare us for exponential times” Dion Hinchcliffe
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Change is changing
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What approaches to change are needed in this environment?
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Kinthi Sturtevant, IBM 13th
annual Change Management Conference
June 2015
We rarely see two, three or four year change projects any more. Now it’s 30-60-90 day change
projects
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@HelenBevan #RTR2016Source: Bromford P (2015), ”What’s the difference between a test and a pilot?”
Pilots are being replaced by rapid tests and prototypes
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Acceleration of connectedness
Change is changing
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Digital skills are a critical capability for future leaders of improvement
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How does the NHS improvement community prefer to communicate?
Digital
Non-digital
ProactiveReactive
Source: RAND evaluation data from the Q community of improvement leaders
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How does the NHS improvement community prefer to communicate?
Digital
Non-digital
ProactiveReactive
Source: RAND evaluation data from the Q community of improvement leaders
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Hierarchical power is diminishing
Change is changing
Acceleration of connectedness
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Change is changing
Acceleration of connectedness
Hierarchical Power is diminishing
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The Challenges
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Change is changing
Change is moving to the edge
Acceleration of connectedness
Hierarchical Power is diminishing
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An example from the Cabinet Office
http://www.slideshare.net/Openpolicymaking/060715-change-cardscollated?next_slideshow=1
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Why go to the edge?
“Leading from the edge brings us into contact with a far wider range
of relationships, and in turn, this increases our potential for diversity in terms of thought, experience and
background. Diversity leads to more disruptive thinking, faster
change and better outcomesAylet Baron
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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
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The Network Secrets of Great Change AgentsJulie Battilana &Tiziana Casciaro
As a change agent, my centrality in the informal network is more important
than my position in the formal hierarchy
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WHO makes change happen?
Source: adapted by Helen Bevan from Leandro Herrera
List A• The Transformation Programme
Board• The programme sponsor• The Programme Management
Office• The leads of the [insert number]
transformation work streams • The Clinical Director• The Team Leader /Unit Manager• The Change Facilitator
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WHO makes change happen?
List A• The Transformation Programme
Board• The programme sponsor• The Programme Management
Office• The leads of the [insert number]
transformation work streams • The Clinical Director• The Team Leader /Unit Manager• The Change Facilitator
List B• The mavericks and rebels• The deviants (positive). Who do
things differently and succeed• The contrarians, because they can• The nonconformists who see things
through glasses no one else has• The hyper-connected. Good or bad,
they spread behaviours, role model at a scale, set mountains on fire and multiply anything they get their hands on
• The hyper-trusted. Multiple reasons, doesn’t matter which ones
Source: adapted by Helen Bevan from Leandro Herrera
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WHO makes change happen?
List A• The Transformation Programme
Board• The programme sponsor• The Programme Management
Office• The leads of the [insert number]
transformation work streams • The Project Manager• The Team Leader /Unit Manager• The Change Facilitator
List B• The mavericks and rebels• The deviants (positive). Who do
things differently and succeed• The contrarians, because they can• The nonconformists who see things
through glasses no one else has• The hyper-connected. Good or bad,
they spread behaviours, role model at a scale, set mountains on fire and multiply anything they get their hands on
• The hyper-trusted. Multiple reasons, doesn’t matter which ones
Source: adapted by Helen Bevan from Leandro Herrera
People who live and
perform in formal
organisation land and
people with the power
who have make or break
change are two different
lists (and we need BOTH)
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What’s the evidence?The failure of large scale
transformational change projects is rarely due to the content or
structure of the plans that are put into action
To make transformational change happen we need to connect networks
of people who ‘want’ to contribute
http://iedp.com/articles/vertical-leadership/?utm_source=Sign-Up.to&utm_medium=email&utm_campaign=13787-257163-Campaign+-+01%2F09%2F2016
Source: David Dinwoodie (2015)
It’s much more about the role of informal networks in the
organisations/systems affected by change
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Is your change process a cathedral or a bazaar?
http://www.unterstein.net/su/docs/CathBaz.pdf
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We have a lot of cathedrals
Source: Sewell (2015) : Stop training our project managers to be process junkies
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Power in community“Power used to come largely through and from big institutions.Today power can and does come from connected individuals in community.When community invests in an idea, it co-owns its success.
Source of image: orton.org
Instead of trying to achieve scale all by ourselves, we have a new way to have scale. Scale can be in, with and through community.”
Nilofer Merchant
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“I have some Key Performance
Indicatorsfor you”
or
“I have a dream”
Source: @RobertVarnam
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“Tomorrow’s management systems will need to value diversity, dissent
and divergence as highly as conformance, consensus and
cohesion.”Gary Hamel
Image by neilperkin.typepad.com
is the new normal!
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“Tomorrow’s management systems will need to value diversity, dissent
and divergence as highly as conformance, consensus and
cohesion.”Gary Hamel
Image by neilperkin.typepad.com
“The single biggest mistake to avoid? Creating disruption at work. Focus on developing relationships, not disrupting and alienating people. Peter Vander Awera on learning from setbacks and failures
is the new normal!
##FabChangeDay
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What happens to heretics/radicals/rebels/mavericks
in organisations?
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@HelenBevan #RTR2016Source: Lois Kelly http://www.slideshare.net/Foghound/rocking-the-boat-without-falling-out
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We need rebels!•The principal champion of a change initiative, cause or action
•Rebels don’t wait for permission to lead, innovate, strategise
•They are responsible; they do what is right•They name things that others don’t see yet
•They point to new horizons•Without rebels, the storyline never changes
Source : @PeterVan http://t.co/6CQtA4wUv1
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‘If you put fences around people, you get sheep. Give people the room they
needWilliam L McKnight
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We need to create more boat rockers!• Rock the boat but manage to
stay in it• Walk the fine line between
difference and fit, inside and outside
• Conform AND rebel• Capable of working with
others to create success NOT a destructive troublemaker
Source: Debra Meyerson
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There’s a big difference between a rebel and a troublemaker
Rebel
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Reflection• What are your insights around “rebels” and
“troublemakers”?• What moves people from being “rebel” to
“troublemaker”?• How do we protect against this?
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There’s a big difference between a rebel and a troublemaker
Rebel
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For our break, we will have a RCT
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• Randomised Coffee Trial!• Randomised Coffee Trial!
Randomised Coffee Trial!
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Outcomes of Randomised Coffee Trials
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@HelenBevan #RTR2016fabnhsstuff.net/fabchangeday/rct/ or google “Fab stuff RCT”
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Join in one of our national Randomised Coffee Trials
fabnhsstuff.net/fabchangeday/rct/ 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 forPatient Safety – for anyone with an interest in ensuring patient safety across the health and social care systemHome First – looking at the issues around how people who have long-term health conditions receive care outside of hospitalLearning and Leading Together – for anyone interested in how patients and healthcare staff can work together in genuine partnershipMatExp – for anyone interested in improving maternity experience – women and families as well as professionals
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Sign up for action with the Fab Change Day app
app.fabchangeday.net
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Change starts with me
Source of image: jasonkeath.com
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‘I do not think you can really deal with change without a person asking real
questions about who they are and how they belong in the world’
David Whyte, The Heart Aroused 1994
Source of image: fistfuloftalent.com
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1. able to join forces with others to create action2. able to achieve small wins which create a sense
of hope, possibility and confidence3. More likely to view obstacles as challenges to
overcome4. strong sense of “self-efficacy”
belief that I am personally able to create the change
Four things we know about successful boat rockers
Source: adapted from Debra E Meyerson
CHANGE
meBEGINS WITH
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Self-efficacy
“If you think you can or think you
can't, you are right.”
Henry Ford
“The ability to act is tied to a belief that it is possible to do so”
Albert Bandura
There is a positive, significant relationship between the self-efficacy beliefs of a
change agent and her/his ability to facilitate change
and get good outcomes
Source of image:www.h3daily.com
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Source: @NHSChangeDay
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Source: @NHSChangeDay
What is the issue here?“permission” ?
(externally generated)or
Self efficacy ? (internally generated)
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Building self-efficacy: some tactics1. Create change one small step at a time2. Reframe your thinking:
• failed attempts are learning opportunities• uncertainty becomes curiousity
3. Make change routine rather than an exceptional activity4. Get social support5. Learn from the best
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#RTR2016
@HelenBevan #RTR2016Image copyright: http://13c4.wordpress.com/2007/02/24/50-reasons-not-to-change/
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#RTR2016
@HelenBevan #RTR2016
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#RTR2016
@HelenBevan #RTR2016
C http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively
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#RTR2016
@HelenBevan #RTR2016Source: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively
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#RTR2016
@HelenBevan #RTR2016Source: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively
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#RTR2016
@HelenBevan #RTR2016Source: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively
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#RTR2016
@HelenBevan #RTR2016Source: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively
![Page 68: Rewriting the Rules: Enduring and Emerging Approaches to Change](https://reader035.fdocuments.us/reader035/viewer/2022062412/58f9b27b760da3da068bcbd2/html5/thumbnails/68.jpg)
#RTR2016
@HelenBevan #RTR2016Source: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively
Make it a personal PERFORMANCE target.
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#RTR2016
@HelenBevan #RTR2016Source: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively
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#RTR2016
@HelenBevan #RTR2016
Research from the sales industry:How many NOs should we be seeking to get?
• 2% of sales are made on the first contact• 3% of sales are made on the second contact• 5% of sales are made on the third contact• 10% of sales are made on the fourth contact• 80% of sales are made on the fifth to twelfth contact
Source: http://www.slideshare.net/bryandaly/go-for-no
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#RTR2016
@HelenBevan #RTR2016
“Papers that are more likely to contend against the status quo are more likely to find an opponent in the review system—and thus be rejected —but
those papers are also more likely to have an impact on people across the system, earning them
more citations when finally published”V. Calcagno et al., “Flows of research manuscripts among
scientific journals reveal hidden submission patterns,” Science, doi:10.1126/science.1227833, 2012.
—
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#SHCR @HelenBevan #@HelenBevan
Being a great change agent is about knowing, doing, living and being improvement
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#SHCR @HelenBevan #@HelenBevan
Avedis Donabedian
“Ultimately, the secret of quality is love.…… If you have love, you can then work backward to monitor and improve the system”.
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#SHCR @HelenBevan #@HelenBevanProject Aristotle: http://qz.com/625870/after-years-of-intensive-analysis-google-discovers-the-key-to-good-teamwork-is-being-nice/
After years of intensive analysis, Google discovers that the key to high performing,
innovative teams is being nice
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#SHCR @HelenBevan #@HelenBevan
Key tactic :Out-love everyone else
Source of image: Bradley Burgess
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#SHCR @HelenBevan #@HelenBevan
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#SHCR @HelenBevan #@HelenBevan
“Stages of change” Transtheoretical model of behaviour change
Prochaska, DiClemente & Norcross (1992)
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#SHCR @HelenBevan #@HelenBevan
• smoking cessation • exercise adoption• alcohol and drug use• weight control • fruit and vegetable intake• domestic violence• HIV prevention• use of sunscreens to prevent skin cancer • medication compliance • mammography screening
The model is mostly used around health-related behaviours
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#SHCR @HelenBevan #@HelenBevan
• smoking cessation • exercise adoption• alcohol and drug use• weight control • fruit and vegetable intake• domestic violence• HIV prevention• use of sunscreens to prevent skin cancer • medication compliance • mammography screening
It works for organisational and service change too!
The model is mostly used around health-related behaviours
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#SHCR @HelenBevan #@HelenBevan
“Stages of change” Smoking
I am not aware my smoking is a
problem – I have no intention to quit
Prochaska, DiClemente & Norcross (1992)
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#SHCR @HelenBevan #@HelenBevan
“Stages of change” Smoking
I am not aware my smoking is a
problem – I have no intention to quit
I know my smoking is a problem – I
want to stop but no plans yet
Prochaska, DiClemente & Norcross (1992)
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#SHCR @HelenBevan #@HelenBevan
I am not aware my smoking is a
problem – I have no intention to quit
I know my smoking is a problem – I
want to stop but no plans yet
I am making plans & changing things
I do in preparation.
“Stages of change” Smoking
Prochaska, DiClemente & Norcross (1992)
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#SHCR @HelenBevan #@HelenBevan
I am not aware my smoking is a
problem – I have no intention to quit
I know my smoking is a problem – I
want to stop but no plans yet
I am making plans & changing things
I do in preparation.
I have stopped
smoking!
“Stages of change” Smoking
Prochaska, DiClemente & Norcross (1992)
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#SHCR @HelenBevan #@HelenBevan
I am not aware my smoking is a
problem – I have no intention to quit
I know my smoking is a problem – I
want to stop but no plans yet
I am making plans & changing things
I do in preparation.
I have stopped
smoking!
I am continuing to not smoke.
I sometimes miss it – but I am still not
smoking
“Stages of change” Smoking
Prochaska, DiClemente & Norcross (1992)
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#SHCR @HelenBevan #@HelenBevan
I am not aware my smoking is a
problem – I have no intention to quit
I know my smoking is a problem – I
want to stop but no plans yet
I am making plans & changing things
I do in preparation.
I have stopped
smoking!
I am continuing to not smoke.
I sometimes miss it – but I am still not
smoking
“Stages of change” Smoking
Prochaska, DiClemente & Norcross (1992)
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#SHCR @HelenBevan #@HelenBevan
Prochaska, DiClemente & Norcross (1992)
“Stages of change” Transtheoretical model of behaviour change
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#SHCR @HelenBevan #@HelenBevan
• Which stage do most change activities in health and care focus on?
• Which stage are most people actually at?
Some questions
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#SHCR @HelenBevan #@HelenBevan
The reality of our change situation• Our tools are often not effective at the stage of change
that most people we work with are at• It’s hard to engage people in change• It’s hard to get people to make the changes we want
them to make• People get irritated, defensive, irrational• We feel powerless in our ability to lead or facilitate the
change
90% of the tools available for health and care change agents are designed for the “action” stage
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#SHCR @HelenBevan #IQTGOLD@HelenBevan
• Designed for Stage 4 – ACTION!
• Mandated it through targets
• Despite compelling case for change – people often resisted it
• People did the task and missed the point
Example – WHO Surgical Safety Checklist
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#SHCR @HelenBevan #IQTGOLD@HelenBevan
Source: Russ et al (2015) A Qualitative Evaluation of the Barriers and Facilitators Toward Implementation of the WHO Surgical Safety Checklist Across Hospitals in England: Lessons From the “Surgical Checklist Implementation Project” Ann Surg
Source of infographic here
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#SHCR @HelenBevan #IQTGOLD@HelenBevan
“In hospitals without adequate resources and efficient systems, simply requiring the checklist to be used might not only fail to improve patient safety but might also introduce new risks for staff and
patients. This is the exact opposite of what the checklist was designed to achieve”.
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#SHCR @HelenBevan #@HelenBevan
• Lower our ambitions for improvement• Focus our energies on those who are
already in the “action” stage• Put negative labels on those who are
not yet at the action stage such as “blocker” or “resister” or “laggard”
• Blame “the management” for not enforcing change
So what do we TEND to do when people resist?
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#SHCR @HelenBevan #@HelenBevan
The single biggest problem in communication is the illusion that it has taken
place
George Bernard Shaw
‘‘
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#SHCR @HelenBevan #@HelenBevan
• Listen and understand• appreciate the starting point• elaborate interests
• Roll with resistance• Don’t argue against it• Be curious and accepting• Encourage elaboration of resistance
• What makes it so hard?• What would help?
• Build meaning and conviction in the change
So what SHOULD we do?
See Motivational interviewing as a change management strategy
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#SHCR @HelenBevan #@HelenBevan
• The focus should be on creating awareness for me of the need to change
• Remember the goal is not to make me (as a precontemplator) change immediately, but to help me move to contemplation
Example from the worksheet
• I am not thinking about changing my behaviours, actions or work processes
• The problem or issue is outside my frame of awareness or my perceived need
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#SHCR @HelenBevan #@HelenBevan
If your horse dies, get off itCherokee proverb
Source of image: fenwickgallery.co.uk
‘‘
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#SHCR @HelenBevan #@HelenBevan
Focussing on Prochaska, DiClemente and Norcross’s Stages of Change model: • What stage of change are some of the key
people that you need to influence for your change initiative at?
• What actions can you take to help them move to the next stage?
Thinking about your own situation
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#SHCR @HelenBevan #IQTGOLD@HelenBevan
“The test of a first-rate intelligence is the ability to hold two opposed ideas in the mind at the same time and still retain the ability to function”F Scott FitzgeraldAuthor, 1896-1940
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#SHCR @HelenBevan #IQTGOLD@HelenBevan
“Every conflict is an invitation to innovation.”
Mary Parker FollettSociologist, 1868-1933
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#SHCR @HelenBevan #IQTGOLD@HelenBevan@HelenBevan
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#SHCR @HelenBevan #@HelenBevan
Polarities in today’s workshop
Old power AND New power List A AND List B
Hierarchies AND Networks Transactions AND Relationships
At the edge AND In the centre On the inside AND On the outside
Change methods AND Emergent change
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#SHCR @HelenBevan #IQTGOLD@HelenBevan
Polarity map concept
Source: Barry Johnson
+
–New powerOld power
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#SHCR @HelenBevan #IQTGOLD@HelenBevan
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#SHCR @HelenBevan #IQTGOLD@HelenBevan
Polarity map concept
Source: Barry Johnson
Centralise Decentralise
+
–Centralise DecentraliseDecentraliseCentralise
Either-Or
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#SHCR @HelenBevan #IQTGOLD@HelenBevan
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#SHCR @HelenBevan #IQTGOLD@HelenBevan
Q is a thriving, effective community of improvement leaders
The Q community fails to fulfil its potential
Example
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#SHCR @HelenBevan #IQTGOLD@HelenBevan
Positive results of focus on this left pole
Negative results of over-focus on the left pole to the neglect of the right pole
Negative results of over-focus on the right pole to the neglect of the left pole
Deeper Fear from lack of balance
Greater Purpose Statement - why balance this polarity?*
and
Adapted from the Polarity Management map, Polarity Associates
Polarity MapAction stepsHow will we gain or maintain the positive results from focusing on this left pole? What? Who? By When? Measures?
Action StepsHow will we gain or maintain the positive results from focusing on this right pole? What? Who? By When? Measures?
Early Warnings Measurable indicators (things you can count) that will let you know that you are getting into the downside of this left pole.
Early WarningsMeasurable indicators (things you can count) that will let you know that you are getting into the downside of this right pole.
Positive results of focus on this right pole
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#SHCR @HelenBevan #IQTGOLD@HelenBevan