© NHS Institute for Innovation and Improvement, 2011 Creating contagious commitment to change to deliver results in challenging times Helen Bevan NHS Institute for Innovation and Improvement

© NHS Institute for Innovation and Improvement, 2011 Leaders ask their staff to be ready for change, but do not engage enough in sensemaking Sensemaking is not done via marketing...or slogans but by emotional connection with employees Ron Weil

© NHS Institute for Innovation and Improvement, 2011 A question Where would you start if you wanted to improve quality and reduce costs at unprecedented scale and pace?

© NHS Institute for Innovation and Improvement, 2011 “ Revolution begins with transformation of consciousness” Paul Bate

© NHS Institute for Innovation and Improvement, 2011 Which tradition of change? Management of change Organising and mobilising

© NHS Institute for Innovation and Improvement, 2011 Which tradition of change? Organisational behaviour Leadership and management studies Clinical/medical audit Improvement “science” Academic tradition(s) – 100 years Management of change

© NHS Institute for Innovation and Improvement, 2011 Which tradition of change? Community organising, campaigns and social movements Learning from popular, civic and faith-based mobilisation efforts. Academic tradition– 100 years Organising and mobilising

© NHS Institute for Innovation and Improvement, 2011 Which tradition of change? Organisational behaviour Leadership and management studies Clinical/medical audit Improvement “science” Academic tradition(s) – 100 years Community organising, campaigns and social movements Learning from popular, civic and faith-based mobilisation efforts Academic tradition – 100 years Management of change Organising and mobilising

© NHS Institute for Innovation and Improvement, 2011 Where would you start? 1.create a “burning platform” and imperative for action around quality and cost improvement

© NHS Institute for Innovation and Improvement, 2011 Where would you start? 1.create a “burning platform” and imperative for action around quality and cost improvement 2.develop a strong narrative (story) around how cost improvement can be delivered through quality

© NHS Institute for Innovation and Improvement, 2011 Where would you start? 1.create a “burning platform” and imperative for action around quality and cost improvement 2.develop a strong narrative (story) around how cost improvement can be delivered through quality 3.make a clinically relevant case that makes both a rational case for change and a connection to emotions, through values

© NHS Institute for Innovation and Improvement, 2011 Where would you start? 1.create a “burning platform” and imperative for action around quality and cost improvement 2.develop a strong narrative (story) around how cost improvement can be delivered through quality 3.make a clinically relevant case that makes both a rational case for change and a connection to emotions, through values 4.make it “real” for frontline staff (e.g., 200 patients and £5k per person per year)

© NHS Institute for Innovation and Improvement, 2011 Where would you start? 1.create a “burning platform” and imperative for action around quality and cost improvement 2.develop a strong narrative (story) around how cost improvement can be delivered through quality 3.make a clinically relevant case that makes both a rational case for change and a connection to emotions, through values 4.make it “real” for frontline staff (e.g., 200 patients and £5k per person per year) 5.ask people to commit to specific actions

© NHS Institute for Innovation and Improvement, 2011 Anatomy of changePhysiology of change Definition The shape and structure of the system; detailed analysis; how the components fit together. The vitality and life-giving forces that enable the system and its people to develop, grow and change. Focus Processes and structures to deliver health and healthcare. Energy/fuel for change. Leadership activities  measurement and evidence  improving clinical systems  reducing waste and variation in healthcare processes  redesigning pathways  creating a higher purpose and deeper meaning for the change process  building commitment to change  connecting with values  creating hope and optimism about the future  calling to action

© NHS Institute for Innovation and Improvement, 2011 The ten key principles of large scale change 1.Movement towards a new vision that is better and fundamentally different from the status quo 2.Identification and communication of key themes that people can relate to and that will make a big difference 3.Multiples of things (‘lots of lots’) 4.Framing the issues in ways that engage and mobilise the imagination, energy and will of a large number of diverse stakeholders in order to create a shift in the balance of power and distribute the leadership 5.Mutually reinforcing change across multiple processes/subsystems

© NHS Institute for Innovation and Improvement, 2011 The ten key principles of large scale change 6.Continually refreshing the story and attracting new, active supporters 7.Emergent planning and design, based on monitoring progress and adapting as you go 8.Many people contribute to the leadership of change, beyond organisational boundaries 9.Transforming mindsets, leading to inherently sustainable change 10.Maintaining and refreshing the leaders’ energy over the long haul

© NHS Institute for Innovation and Improvement, 2011

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

© NHS Institute for Innovation and Improvement, 2011 “Rules cannot substitute for character” Alan Greenspan US Federal Reserve

© NHS Institute for Innovation and Improvement, 2011 mobilising versus organising

© NHS Institute for Innovation and Improvement, 2011 A cynic, after all, is a passionate person who does not want to be disappointed again Zander R and Zander B (2000) The art of possibility. Harvard Business School Press. As quoted by Steve Onyett

© NHS Institute for Innovation and Improvement, 2011 How did the great social movement leaders change the world? Source: Marshall Ganz Shared understanding leads to Action Narrative why? Strategy what?

© NHS Institute for Innovation and Improvement, 2011 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

© NHS Institute for Innovation and Improvement, 2011 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

© NHS Institute for Innovation and Improvement, 2011 If we want people to take action, we have to connect with their emotions through values action values emotion Source: Marshall Ganz

© NHS Institute for Innovation and Improvement, 2011

But not all emotions are equal inertia urgency anger apathy solidarity isolation you can make a difference Self-doubt hope fear Overcome Action motivatorsAction inhibitors

© NHS Institute for Innovation and Improvement, 2011 What the framing literature tells us “‘a new idea must be at the least couched in the language of past ideas; often, it must be, at first, diluted with vestiges of the past” Saul Alinsky Rules for Radicals (1971)

© NHS Institute for Innovation and Improvement, 2011 What the framing literature tells us In other words.... People are much more likely to embrace change if it is framed as something that builds positively on what they are familiar with than as something that seems far away and unachievable.

© NHS Institute for Innovation and Improvement, 2011 Helen’s photo

© NHS Institute for Innovation and Improvement, 2011

“When you have gone as far that you can’t manage one more step, then you have gone just half the distance that you are capable of” Proverb of the Inuit people of the Arctic Circle

© NHS Institute for Innovation and Improvement, 2011 What do we need to do? 1.Tell a story

© NHS Institute for Innovation and Improvement, 2011 What do we need to do? 1.Tell a story 2.Make it personal

© NHS Institute for Innovation and Improvement, 2011 What do we need to do? 1.Tell a story 2.Make it personal 3.Be authentic

© NHS Institute for Innovation and Improvement, 2011 What do we need to do? 1.Tell a story 2.Make it personal 3.Be authentic 4.Create a sense of “us” (and be clear who the “us” is)

© NHS Institute for Innovation and Improvement, 2011 What do we need to do? 1.Tell a story 2.Make it personal 3.Be authentic 4.Create a sense of “us” (and be clear who the “us” is) 5.Build in a call for urgent action

© NHS Institute for Innovation and Improvement, 2011 Three components of a great narrative (story) Diagnostic – what is the problem that we are addressing? What is the extent of the problem? What is the specific source or sources? Prognostic – what could the future look like? What is our “plan of attack” and our strategy for carrying out the plan? Motivational – why is this urgent? What is our call for action that connects with the motivational and emotional drivers of the audience?

© NHS Institute for Innovation and Improvement, 2011 “The most common way people give up their power is by thinking they don't have any” Alice Walker

© NHS Institute for Innovation and Improvement, 2011 The leader’s most basic role is to release the human spirit that makes initiative, creativity, and entrepreneurship possible Bartlett and Ghoshal

© NHS Institute for Innovation and Improvement, 2011 “In everybody’s life, at some time, our inner fire goes out. It is then burst into flame by an encounter with another human being. We should all be thankful for those people who rekindle the human spirit” Albert Schweitzer