1. © NHS Institute for Innovation and Improvement, 2011 Creating contagious commitment to change Our journey so far Catherine Holmes NHS Institute for Innovation and Improvement

2. © NHS Institute for Innovation and Improvement, 2011 Today To share our learning around creating change at scale Tell you about our call to action and recruit you to join us Test out a new leadership practice Tap into all of you as a collective resource Enjoy ourselves

3. © NHS Institute for Innovation and Improvement, 2011 Building the mobilisation movement for quality and cost improvement What it might take to mobilise our staff, communities and people who use our services at scale to achieve cost and quality improvement Leadership actions we can take to shift power in the system and get the outcomes we seek Strategies for building change on a platform of commitment rather than just compliance How to create a compelling narrative for our quality and cost improvement efforts that builds a sense of urgency and a call for action that results in sustainable change

4. © NHS Institute for Innovation and Improvement, 2011 Three things that unite us 1.We are leaders who are called to serve those in need 2.We want to help secure the future of the NHS (and the principles it stands for) by helping to deliver high quality care/support that makes best use of precious resources 3.We are prepared to invest in our own learning because we hope there might be some additional perspective, knowledge, skills and relationships that can help us in this quest

5. © NHS Institute for Innovation and Improvement, 2011

7. Dementia Action Alliance Our goal By 31 st 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

8. © NHS Institute for Innovation and Improvement, 2011 Why a call to action? Which tradition of change? Management of change Organising and mobilising

9. © 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

10. © 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

11. © 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

12. © 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 Organisin g and mobilising

13. © NHS Institute for Innovation and Improvement, 2011 How an “organising” approach can contribute to our quality and cost goals 1.Build capacity for change and enable others 2.Motivate and mobilise others to action by connecting with emotions, through values 3.Create a sense of “us” as the platform of a movement for change 4.Build commitment, not just compliance 5.Create focus by identifying the small number of actions that people can commit to 6.Shift power in the system to people who deliver services, people who use services, local communities

14. © NHS Institute for Innovation and Improvement, 2011 “Often change need not be cajoled or coerced. Instead it can be unleashed.” Kelman, S. (2005) Unleashing Change. A study of organizational renewal in government, Brookings Institution Press; Washington, D.C

15. © NHS Institute for Innovation and Improvement, 2011 Focus: energy for change imagination engagement moving mobilising calling to action creating the future The ‘clinical system’ mindset for improvement Focus: effectiveness and efficiency metrics and measurement; clinical systems improvement, reducing variation, pathway redesign, evidence based practice How do we create improvement at scale? The ‘mobilisation’ mindset for improvement NHS Institute for Innovation and Improvement 2010 Source: NHS Institute for Innovation and Improvement (2009) The Power of One, The Power of Many

16. © NHS Institute for Innovation and Improvement, 2011 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 Approaches to change

17. © 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

18. © NHS Institute for Innovation and Improvement, 2011 Five leadership messages to consider 1.In our new world, we need levers for commitment, not just compliance 2.We build commitment to actions, not just outcomes 3.Mobilising for change isn't enough; we need to organise 4.We seek to turn the resources we have into the power we need to win the change we want 5.As quality and cost improvement is here for the long haul, we need to manage our own energies and those of the people around us

19. © NHS Institute for Innovation and Improvement, 2011 Challenge no 1 There is a lot of activity and energy for change....... Unless that energy is translated into appropriate action that improves outcomes, it counts for nothing How do we provide a focus and an energy that moves everyone in the same direction?

20. © 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?

21. © NHS Institute for Innovation and Improvement, 2011 On your tables- Think of a social movement you have been involved with – Why did you take part? what were its features? What actions were you required to take?

22. © 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

23. © NHS Institute for Innovation and Improvement, 2011 OUR GOALS AND OUR PROGRESS

24. © NHS Institute for Innovation and Improvement, 2011 Dementia Action Alliance Our goal By 31 st 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

25. © NHS Institute for Innovation and Improvement, 2011 Our strategy To launch a nationwide “call to action” To work in partnership with the Dementia Action Alliance and other networks and organisations that can make a contribution To engage everyone who can play a part in helping to achieve our goal To move beyond mobilising to organising to make this happen

26. © NHS Institute for Innovation and Improvement, 2011 What did we need to agree? Who we are calling to action What actions we want them to take The sources of support and resources that will be made available to help them in their actions

27. © NHS Institute for Innovation and Improvement, 2011 Priority groups to call to action The clinical decision makers who prescribe and review therapeutic interventions Those who we want to shift power to (e.g., people with dementia and their carers) Those who can give voice and advocacy to people with dementia and their carers Those with authority who can promote and ensure best practice

28. © NHS Institute for Innovation and Improvement, 2011 Eight groups to call to action People with dementia and their carers Leaders of care homes GPs and primary care teams Psychiatrists and mental health teams Pharmacists Hospital doctors and multi disciplinary teams Commissioners of health and social care Medical Directors and Nurse Directors of acute and mental health trusts/providers

29. © NHS Institute for Innovation and Improvement, 2011 Making 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

30. © NHS Institute for Innovation and Improvement, 2011 Establish a clear dialogue and agree joint working practices for reviews with all prescribing partners I (we) commit to: reviewing the people under my care to identify those who are prescribed antipsychotic medication and working in partnership with my prescribing and other healthcare colleagues to review each individual by 31st March 2012 I (we) commit to: reviewing the people under my care to identify those who are prescribed antipsychotic medication and working in partnership with my prescribing and other healthcare colleagues to review each individual by 31st March 2012 Take on best practice guidelines for the prescribing of antipsychotic medication and alternative interventions or people with dementia. Provide support and sign-posting to alternative resources for people with dementia and their carers Community pharmacists: Query every prescription for an antipsychotic for people aged 65 years and over and search for, and audit, all people 65 years and over who have received antipsychotic medication in the last 3 months Community pharmacists: Query every prescription for an antipsychotic for people aged 65 years and over and search for, and audit, all people 65 years and over who have received antipsychotic medication in the last 3 months Hospital pharmacists: Query every prescription for an antipsychotic for people aged 65 years and over and ensure that discharge information is up to date regarding the actions GPs should take (in line with NICE guidelines) Hospital pharmacists: Query every prescription for an antipsychotic for people aged 65 years and over and ensure that discharge information is up to date regarding the actions GPs should take (in line with NICE guidelines) CALLTO ACTION FOR PHARMACISTS What specific action? What are the main themes for action?

31. © NHS Institute for Innovation and Improvement, 2011 Telling your own story and securing commitment

32. © 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?

33. © NHS Institute for Innovation and Improvement, 2011

34. If we want people to take action, we have to connect with their emotions through values action values emotion Source: Marshall Ganz

35. © NHS Institute for Innovation and Improvement, 2011 And not all emotions are equal......... inertia urgency anger apathy solidarity isolation you can make a difference Self-doubt hope fear Overcome Action motivatorsAction inhibitors

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

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

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

39. © 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)

40. © NHS Institute for Innovation and Improvement, 2011 What do we need to do?(narrative) Tell a story Make it personal Be authentic Create a sense of “us” (and be clear who the “us” is) Build in a call for urgent action Identify the intolerable condition Outline the nightmare if we fail to act. Offer hope and Call people to join us in taking a specific action

41. © NHS Institute for Innovation and Improvement, 2011 Ghandi While you listen please consider the following: What values did you hear? What was the nightmare situation he described? How did he offer hope? What choices did he offer? How did he build a sense of us? What action did he ask people to take ?

42. © NHS Institute for Innovation and Improvement, 2011 Debrief

43. © NHS Institute for Innovation and Improvement, 2011 “How wonderful it is that nobody need wait a single moment before starting to improve the world” Anne Frank, Diary of a Young Girl, 1945

44. © NHS Institute for Innovation and Improvement, 2011 How do we create a sense of “us” to build a movement for change in health and healthcare?

45. © NHS Institute for Innovation and Improvement, 2011 strong ties versus weak ties

46. © NHS Institute for Innovation and Improvement, 2011 When we 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

47. © NHS Institute for Innovation and Improvement, 2011 The pros and cons of a strong tie strategy AdvantagesLimitations

48. © NHS Institute for Innovation and Improvement, 2011 Strong and 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 o f 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 potentially help achieve our goals

49. © NHS Institute for Innovation and Improvement, 2011 Why we need to build weak ties AS WELL as strong ties Weak ties are typically a more effective starting point for influence at scale because they enable us to access large portions of the population, with fewer barriers than strong ties In situations of uncertainty, we have a tendency to revert to our strong tie relationships; yet the evidence tells us that weak ties are much more important than strong ties when it comes to searching out resources in times of scarcity. Our best new ideas about how to deliver more effectively with less - and the most breakthrough innovations of the NHS - will come when we tap into our weak ties History suggests that a weak ties strategy will probably give us the best chance to deliver the scale of improvements we seek in quality and cost in a challenging timescale

50. © NHS Institute for Innovation and Improvement, 2011 leadership messages for you to consider 1.The traditional “strong ties” model of spreading change in the NHS offers both strengths and limitations 2.The “weak ties” philosophy underpinning many successful social movements helps us to build common ground between disparate groups and individuals 3.Our best new ideas about how to deliver more effectively with less - and the most breakthrough innovations of the NHS - will come when we tap into our weak ties 4.When, as leaders, we call people to action, we should include diagnostic, prognostic and motivational elements in the framing of the message

51. © NHS Institute for Innovation and Improvement, 2011 Three components of “core framing” Diagnostic framing - aims to identify the problem that the movement will address and attribute the problem to a specific source or sources- Prognostic framing - relates to the creation of a plan of attack and clear strategies for carrying out the plan Motivational framing - typically stresses urgency and an overall duty of/ call for action that connects with the motivational and emotional drivers of the audience.

52. © NHS Institute for Innovation and Improvement, 2011 Diagnostic framing In the UK 180,000 people a year are treated with antipsychotic medication Of those only 36,000 receive any benefit from this treatment The resulting 144,000 people receive the medication needlessly as staff and carers are often unaware of alternative therapies As a result over 1600 people experience an adverse cerebral event and 1800 people die needlessly because of taking inappropriately prescribed anti- psychotic medication. Reducing anti-psychotic medication in two thirds of people with Dementia would result in a potential saving of £55 Million

53. © NHS Institute for Innovation and Improvement, 2011 Prognostic framing To deliver on the national ambition of reducing anti-psychotic prescribing by two thirds by Nov 2011 we all have a part to play. Maximise the opportunities of the Dementia Declaration to bring local organisations together to discuss improvement across local communities and ensure that the voice of the person drives service improvement We need every PCT and local authority to outline plans to audit anti- psychotic prescribing practice and adopt best practice We need every GP to undertake a prescribing and treatment review of every patient with Dementia and agree shared decisions regarding treatment options. We need every care home team to review each of their residents and in partnership with them consider use of alternative therapies. We need every acute Trust to provide training in dementia to ensure that people with dementia spend as less time as possible in acute care and receive appropriate medication.

54. © NHS Institute for Innovation and Improvement, 2011 Motivational framing I’m not dying with dementia, I’m living with it. I don’t want to be left on the shelf”. I want you to count up to 7……. Every 7 seconds someone is diagnosed with dementia and currently many face a bleak life sentence. Every day 5 people die and 4 people experience significant harm as a result of taking medication they may not need. We have the opportunity to give a voice back to 144,000 people with Dementia-by stopping unnecessary antipsychotic prescribing and agreeing with them their options for treatment and support And in doing so have the power to save 1800 lives and prevent over 1600 adverse cerebral events The task ahead is within our grasp-it is the equivalent of every GP reviewing just 9 people a year -less than 1 per month.

55. © NHS Institute for Innovation and Improvement, 2011 Relationships: securing Commitment

56. © NHS Institute for Innovation and Improvement, 2011 Our organising principle We work on the principle that we need commitment to succeed And that we must invest significant time and intention in building relationships that generate commitment Commitment to each other (“us”) and commitment to our goals

57. © NHS Institute for Innovation and Improvement, 2011 So how do we develop commitment..... through relationships Relationships are rooted in shared values and we learn our shared values through shared stories, understanding the choice points for people and asking “why”

58. © NHS Institute for Innovation and Improvement, 2011 Relationships develop through exchanges Relationships grow out of exchanges of interests and resources The key is identifying these interests and resources We are not simply looking for someone to meet our need we are looking to build leaders to join us Growing our constituency

59. © NHS Institute for Innovation and Improvement, 2011 INTERESTS RESOURCES INTERESTS COMMMITMENT

60. © NHS Institute for Innovation and Improvement, 2011 Commitment An exchange between people becomes a relationship when we give a portion of our most valuable resource…….time A commitment of time gives the relationship a future and, therefore, a past And as we learn and grow so does the relationship offering possibilities for enriched exchanges

61. © NHS Institute for Innovation and Improvement, 2011 The more we share Over time we nurture and learn We continue to grow and build our relationships We develop new relationships that offer greater resources and possibilities Sometimes simply knowing that we are not fighting alone give us the energy to carry on to keep committing to our goal

62. © NHS Institute for Innovation and Improvement, 2011 So to recap Relationships are rooted in shared values Relationships grow out of exchanges of interests and resources Relationships are created by commitment

63. © NHS Institute for Innovation and Improvement, 2011 Building intentional relationships One to one and the 5 do’s Attention Interest Exploration Exchange Commitment

64. © NHS Institute for Innovation and Improvement, 2011 Attention Don’t be vague be upfront Why are you meeting this person? Take time to understand their values by sharing yours Do you have a common goal? Be open about your agenda

65. © NHS Institute for Innovation and Improvement, 2011 Interests What is your goal? What do you want to achieve from the meeting? Have you planned this one to one address your call to action interests?

66. © NHS Institute for Innovation and Improvement, 2011 Exploration A large proportion of your one to one should be about exploring to learn the other person’s values, interests and resources What resources do you have that they could potentially need or use? This is a two way process

67. © NHS Institute for Innovation and Improvement, 2011 Exchange We learn to share We exchange our resources information and insight.....which creates a foundation to build on to develop your relationship and explore further your shared commitments

68. © NHS Institute for Innovation and Improvement, 2011 Commitment Good one to ones end with a commitment Meeting again Make it real, not it was nice to see you... see you again Can we make a pledge

69. © NHS Institute for Innovation and Improvement, 2011 Intention prevents failure Do plan this meeting in Don’t be unclear about purpose and time Plan to listen Don’t try to persuade rather than listen Follow the 5 do’s Don’t chit chat about private interests Share experiences and motivations Don’t skip bits to get to the point Share a vision of interests and hope Don’t miss the opportunity to discuss change Be clear about next steps Don’t end without a clear plan

70. © NHS Institute for Innovation and Improvement, 2011 Group work 20 minutes Break into pairs and practice a one to one Go deep and ask some probing questions After 10 minutes switch over Listen out carefully and make note when you hear Your common values Your shared interests Your skills and resources Did you secure a commitment?

71. © NHS Institute for Innovation and Improvement, 2011 Debrief 5 Minutes Did it work? What made it work? What kind of reaction did you get from your counterparts? What did you learn about the values you shared? About common interests? About the resources each of you bring? What did you find particularly challenging ?

72. © NHS Institute for Innovation and Improvement, 2011 Gladys Wilson and Naomi Feil

73. © NHS Institute for Innovation and Improvement, 2011 Make a commitment towards this call to action Join the Call to Action platform Share your resources Build your weak ties Commit to having a 121 in next 14 days and email me and tell me how it went.