Engaging clinicians and managers to create contagious commitment to change to deliver results in challenging times Caroline Chipperfield 15th September 2011

We have 60 minutes ! What is Leadership, Mobilising and Organising and Action Introduce the five key leadership practices used within a Call to Action to make change happen How the NHS Institute for Innovation and Improvement’s is calling people to action the NHS

A scenario You are in charge of a trust effort to reduce costs (at an unprecedented scale and pace) by improving quality Where would you start?

Where would you start? create a “burning platform” and imperative for action around quality and cost improvement

Where would you start? create a “burning platform” and imperative for action around quality and cost improvement develop a strong narrative (story) around how cost improvement is delivered through quality

Where would you start? create a “burning platform” and imperative for action around quality and cost improvement develop a strong narrative (story) around how cost improvement is delivered through quality make a clinically relevant case that makes both a rational connection and a connection to values

Where would you start? create a “burning platform” and imperative for action around quality and cost improvement develop a strong narrative (story) around how cost improvement is delivered through quality make a clinically relevant case that makes both a rational connection and a connection to values make it “real” for frontline staff (e.g., 200 patients and £5k per person per year)

More than 80% of our ability to save costs depends on clinical decision making Brent James, Institute for Healthcare Delivery Research Intermountain Healthcare Copyright 2009 NHS Institute for Innovation and Improvement

Which tradition of change? Organising and mobilising Management of change

Which tradition of change? Community organising, campaigns and social movements Learning from popular, civic and faith-based mobilisation efforts Academic tradition – 100 years Organisational behaviour Leadership and management studies Clinical/medical audit Improvement “science” Academic tradition(s) – 100 years Management of change Organising and mobilising

“Often change need not be cajoled or coerced “Often change need not be cajoled or coerced. Instead it can be unleashed.” Whyte (1994: 221) has a similar notion of change and energy being ‘released’ – cross-ref ‘tapping in to sentiment pools to release energy Kelman, S. (2005) Unleashing Change. A study of organizational renewal in government, Brookings Institution Press; Washington, D.C

Compliance Commitment From the old world to the new world 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 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”) Source: Helen Bevan

How do we create improvement at scale? The ‘mobilisation’ mindset for improvement The ‘clinical system’ mindset for improvement Focus: energy for change imagination engagement moving mobilising calling to action creating the future Focus: effectiveness and efficiency metrics and measurement; clinical systems improvement, reducing variation, pathway redesign, evidence based practice Draws on Gareth Morgan’s Images of Organisation: the central thesis of this book is that all theories of organisation and management are based on implicit metaphor, and that metaphors play a paradoxical role: they are vital to understanding and highlighting certain aspects of organisations, while at the same time they restrict understanding by backgrounding or ignoring others. (Poggi) Source: NHS Institute for Innovation and Improvement (2009) The Power of One, The Power of Many NHS Institute for Innovation and Improvement 2010

Deficit based Asset based Approaches to change Deficit based what is wrong? solving problems identifying development and improvement needs gaps and deficiencies to be filled Asset based what is right that we can build on? exploiting existing assets and resources “positive deviance” amplifying what works Source: Helen Bevan

Shared understanding leads to How did the great social movement leaders change the world? Strategy what? Narrative why? Shared understanding leads to Action Source: Marshall Ganz

What is Mobilising and Organising ? Mobilisation... It’s like lots of helium balloons going up into the sky Community organising... grabs the strings of all of those established through 1.1s This collective, based on common values and relationships gives you the power (extra resources) to lift you off the ground towards your goal and cause

Images from social movements you might be familiar with

Achieving Common Purpose through Shared Values and Commitment A Call to Action is Achieving Common Purpose through Shared Values and Commitment

What is leadership in a call to action?

Leadership is taking responsibility for enabling others to achieve shared purpose in the face of uncertainty Prof. Marshall Ganz Harvard Kennedy School

The ‘Lone Ranger’ model… I’m the Leader

The “we’re all leaders” model…

Empowered Leadership

Relational Commitment Key practices of empowered leadership DISORGANISATION Passive Divided Drift Reactive Inaction LEADERSHIP Shared Story (Public Narrative) Relational Commitment (Relationships) Clear Structure Creative Strategy Effective Action (Measurable) ORGANISATION Motivated United Purposeful Initiative Change 25

a skill to motivate others… Public Narrative is… a skill to motivate others… …to join you in action story of self now us

Why I am called to do this work

our shared EXPERIENCE reveals our shared VALUES

we frame the urgency and hopefulness necessary to secure commitment and build momentum towards our shared goal

Values into action values emotion action Source: Marshall Ganz

OVERCOMES Emotion and action inertia urgency apathy anger fear hope INHIBITORS ACTION MOTIVATORS inertia urgency apathy anger OVERCOMES fear hope   isolation solidarity self doubt Y.C.M.A.D. Source: Marshall Ganz

Creating a shared commitment Relationship as Interest Common Interests New Interests Interests Interests Commitment Resources New Resources Common Resources Relationship as Resource Resources

Compliance Commitment From the old world to the new world 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 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”) Source: Helen Bevan

strong ties versus weak ties

Strong and weak ties When we seek to spread change through weak ties: When we seek to spread change through strong ties: we interact with “people like us”, with the same life experiences, beliefs and values Change is “peer to peer”; GP to GP, nurse to nurse, gynaecologist to gynaecologist Influence is spread through people who are strongly connected to each other, like and trust each other IT WORKS BECAUSE: people are far more likely to be influenced to adopt new behaviours or ways of working from those with whom they are most strongly tied When we seek to spread change through weak ties: we build bridges between groups and individuals who were 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 our aim is to mobilise all the resources in our organisation. system or community that can help achieve our goals

Discretionary effort what we willingly do because we want to extent to which we are interested and involved in assisting the organisation in accomplishing its goals an unmanaged and unrealised resource for most organisations represents a range of performance 30-40% above that which is actively realised by an organisation

Work is contractual Effort is personal Discretionary effort Work is contractual Effort is personal

Creating shared strategy Turning what you have Resources Power Outcome Into what you need To get what you want

Resources to improve quality and cost at scale grow diminish Economic resources diminish with use money materials technology Natural resources grow with use discretionary effort relationships commitment Based on principles from Albert Hirschman, Against Parsimony

Power Not a thing, a quality or a trait The influence created by the relationship between interests and resources We grow our capacity for example by… Building relationships with different kinds of people Building different kinds of relationships with people we already work alongside with Enabling others to take action by developing leadership and acquiring new skills Motivating others to act together Giving voice

Change Specific – measurable and clear Concrete – “real” change that is felt and lived Significant – challenging and consequential

Relational Commitment Key practices of empowered leadership DISORGANISATION Passive Divided Drift Reactive Inaction LEADERSHIP Shared Story (Public Narrative) Relational Commitment (Relationships) Clear Structure Creative Strategy Effective Action (Measurable) ORGANISATION Motivated United Purposeful Initiative Change 42

Dementia Action Alliance Our goal By 31st March 2012, all people with dementia who are receiving antipsychotic drugs will have undergone a clinical review to ensure that if they are receiving these drugs they are doing so appropriately and that alternatives to their prescription have been considered and a shared decision has been agreed regarding their future care

How do we work? Launched a nationwide “call to action” on 9th June 2011 We work in partnership with the Dementia Action Alliance , other networks and organisations, that can make a contribution We engage with everyone who can play a part in helping to achieve our goal We have 8 commitment groups We move beyond mobilising to organising to make this happen

National Taskforce for Dementia and Antipsychotics National Clinical Director for Dementia QIPP Lead for Medicines management Alzheimer’s Society Policy Lead Dementia Action Alliance Chair GP lead Junior Drs Lead Care Homes Lead National Clinical Director for Pharmacy DH Social Care and Dementia Lead NHS Institute Call to Action support team

Junior Doctor Call to Action The Department of Health and Dementia Alliance We commit to carefully considering whether or not a prescription for antipsychotic medication is appropriate for someone with dementia who is in hospital and to reviewing the prescription on transfer or discharge from hospital

energy..... One of the most important leadership tasks in the era of quality and cost improvement is to manage our own energies and those of the people around us

Four sources of energy Energy Description Intellectual Emotional Energy of analysis, logic, thinking, rationality. Drives curiosity, planning and focus Emotional Energy of human connection and relationships. Essential for teamwork, partnership, alignment and collaboration Spiritual Energy of vitality, passion, the future and sense of possibility. Brings hope and optimism and helps people feel more ready and confident to build the future Physical Energy of action, making things happen and getting them done. Key part of vitality, maintaining concentration and commitment Source: adapted from Steve Radcliffe

What are the consequences? Question Which energies do we use most in our quality and cost improvement efforts? What are the consequences?

What’s wrong with using intellectual energy? connecting intellect to intellect keeps us in our comfort zone it isn’t transformational We will achieve greater results (pace and scale) if we link physical energy to emotional and spiritual energy In these difficult times, we particularly need spiritual energy

Who understood the need for spiritual energy? “Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide.” Aneurin Bevan, founder of the NHS

The challenge  ”What the leader cares about (and typically bases at least 80% of his or her message to others on) does not tap into roughly 80% of the workforce’s primary motivators for putting extra energy into the change programme” Scott Keller and Carolyn Aiken (2009) The Inconvenient Truth about Change Management

What is the potential for organising in healthcare? Professionally led healthcare Patient/ family as consumer/ receiver of care Clinical professional leads the process, defines the problem and designs the intervention Work occurs at site determined by professional at a time determined by professional Collaborative healthcare Patient/ family active, engaged but still a receiver/ consumer of care Professional proposes, consults, shares decisions on how to proceed More power to patient but this is about isolated individuals in a one to one relationship with the system Citizen healthcare Patient*/ family as co-creator, producer of health May begin with collaborative professional leadership but becomes patient/ family/community led Communities of patients/ families/volunteers are the main definers and contribute to the intervention with professional input Jointly determined sites and locations *Need to change the terminology as the terms such as “patient” or “user” suggests a passive receiver/ consumer of care Source: adapted from the work of Bill Doherty

And as for learning Call to action: mobilising leadership…..

We have a choice “This is the true joy of life, the being used up for a purpose recognised by yourself as a mighty one, being a force of nature instead of a feverish, selfish little clot of ailments and grievances, complaining that the world will not devote itself to making you happy” George Bernard Shaw