managing the human dimensions of change: working with ... · managing the human dimensions of...

Improvement Leaders’ Guide to

Managing the human dimensions of change: working with individuals

For further information seewww.modern.nhs.uk

AcknowledgementsThe development of this guide forImprovement Leaders has been a trulycollaborative process. We would like tothank everyone who has contributed bysharing his or her experiences, knowledgeand case studies.

Design teamHoward Arthur, Sue Beckman, Helen Bevan,Jay Bevington, Triona Buckley, PhilomenaCorrigan, Kevin Cottrell, Jim Easton,Katherine Foreman, Richard Green, JudyHargadon, Ruth Kennedy, Amanda Layton,Mike McBride, Philippa Murphy, SteveO’Neil, Jean Penny, Neil Riley.

Research into Practice ProgrammeThroughout this guide we have used quotesfrom the Research into Practice Programme.This is ongoing research to gain newknowledge on factors influencing the spreadand sustainability of new practices. It islooking at two improvement programmes,the Cancer Services Collaborative and theNational Booking Programme. It is focusingon the factors that influence the spread andsustainability of service improvements andthe factors that change clinical sceptics intosupporters.

Our thanks to Gravesend Medical Centreand the Medway NHS Trust, Kent for theircooperation with the photography.

© 2002 Crown Copyright

Designed by Redhouse Lane, 020 7291 4646Published by Ancient House Printing Group,Ipswich, 01473 232777

Managing the human dimensions of change

www.modern.nhs.uk/improvementguides 1

Foreword

I am pleased to present this guide – another in our series for ImprovementLeaders in the NHS.

Earlier this year we launched the first three guides in this series and it is great toreport how well they have been received by staff from all parts of the NHS andby other partners in healthcare.

In the NHS Modernisation Agency we try to follow five simple rules. These are to: • see things through the patients’ eyes• find a better way of doing things• look at the whole picture• give front line staff the time and the tools to settle the problems• take small steps as well as big leaps

All Improvement Leaders’ Guides are underpinned by these rules, as we feel thatthese are the things that are truly going to make improvements for our patients.

The first guides on Process Mapping, Analysis and Redesign, Matching Capacityand Demand and Measurement for Improvement gave real, practical adviceabout the basics of improvement. These next four guides tackle some of thesofter issues about people:• Managing the human dimensions of change• Involving patients and carers• Sustainability and spread • Setting up a collaborative programme

It is only by testing ideas, learning what works best and sharing our knowledgethat we will really make things better for our patients. The content of theseguides will be updated over time, so if you’ve found this printed version useful,keep checking the website on www.modern.nhs.uk/improvementguidesIt is here that the guides will be regularly updated as we learn more and havenew things to share. There will also be news of more Improvement Leaders’Guides coming in the autumn. These include the topics of working acrossorganisations, leadership in improvement and designing new roles inhealthcare.

Remember that the guides are meant for Improvement Leaders at every level inhealthcare, on the frontline just as much as in the boardroom. We needImprovement Leaders with passion, integrity and energy who can breathe lifeinto the simple rules listed above and make them work on their patch for theirpatients. In many places such local leaders are already achieving tremendousresults, and the guides are here as an extra source of support for everyone inhealthcare.

David FillinghamDirector, NHS Modernisation Agency



The Improvement Leaders’ Guides

Collectively the Improvement Leaders’ Guides form a set of principles for creating the best conditions for improvement in healthcare. The greatest benefit is when they are used to support a programme of training inimprovement techniques.

Where should I start?The seven guides are not sequential and ideally you should read them all at anearly stage in your improvement project to be aware of the tools andtechniques in all the guides. However there are some things we would suggestyou should do first, as you develop your plan based on local needs andexperience.

Each guide includes• some background information on the topic • some activities which you, as an Improvement Leader, may find useful to help

the teams you work with understand the basic principles• questions that are frequently asked about the topic and suggested ways to

answer them• guidance on where to go for more information. Sources include the excellent

toolkits that have been produced to support improvement programmes inspecific services, such as Cancer, Critical Care, Mental Health and ClinicalGovernance. Useful books, papers and websites are also listed


4 www.modern.nhs.uk/improvementguides www.modern.nhs.uk/improvementguides 5


What’s in each guide?

What the guide has to offer an Improvement Leader

This is definitely the place to start. This guide offers help in the use of the ‘Model for Improvement’. This is a framework for setting aims, identifying thepossible changes and beginning to think about measures that will show that yourchanges have made an improvement. Then there is the vital first stage of mappingyour chosen patient process and analysing it to really understand what ishappening.

Question: how do we know a change is an improvement? Answer: by measuringthe impact of the changes. This guide should also be considered very early on in an improvement project and gives valuable advice on what and how to measurefor improvement and how to present the data to interested parties.

In our experience the process of truly matching capacity and demand has led tosome of the most exciting changes in a healthcare process. This guide explains themost effective ways to understand the capacity and demand of a service and the‘bottlenecks’ in the system which often cause patients to wait. It goes on tosuggest ideas to reduce or eliminate these queues and waiting lists for patients. It is vital that process mapping and analysis is done prior to using this guide.

Everything we do should be focused on patients and their carers. They must be involved in our improvement programmes and projects from the very beginning. We are able to offer advice based on current thinking and experience of how to involve patients and carers in the most effective way, with warnings ofpossible pitfalls.

Some of us take to the idea of change more easily than others. Some like todevelop ideas through activities and discussions, while others prefer to have time to think by themselves. We are all different and need to be valued for ourdifferences. This guide gives ideas of how to ensure the best possible outcomewhen working with different people.

It is fundamentally important that after making improvements they are sustainedand built upon. This is a real challenge to anyone involved in improvement projects.It is also important that we share our learning and ideas with other areas ofhealthcare so that the maximum number of patients can benefit. This guidesuggests methods and principles based on experience from healthcare both inEngland and beyond for sustaining and spreading improvement ideas.

Experience has shown that working collaboratively produces the best environmentfor creating and sharing improvement ideas. Use this guide when a group ofhealthcare staff want to work in a different way, to innovate and test new modelsof delivering care, to dramatically improve the service for a group of patients and to create learning for their own organisation and the whole of the NHS.

Improvement Leaders’ Guide to…

Process mapping, analysis and redesignwww.modern.nhs.uk/improvementguides/process

Measurement for improvementwww.modern.nhs.uk/improvementguides/measurement

Matching capacity and demand www.modern.nhs.uk/improvementguides/capacity

Involving patients and carerswww.modern.nhs.uk/improvementguides/patients

Managing the human dimensions of changewww.modern.nhs.uk/improvementguides/human

Sustainability and spreadwww.modern.nhs.uk/improvementguides/sustainability

Setting up a collaborative programmewww.modern.nhs.uk/improvementguides/collaborative


6 www.modern.nhs.uk/improvementguides

Take the thinking forward.The website will be a dynamicmedium. Please contribute to thediscussion if you can. We wouldwelcome and value your experience.

Have fun.Many have said that leading animprovement project has been one ofthe most enjoyable and fulfilling rolesof their career!

Let us know what you think of the guides.We want your comments andthoughts about the ImprovementLeaders’ Guides. Our aim is to keepimproving them so let us know whatyou think.

• how can we improve the guides? Isthere anything we have left out?

• have you found them useful? If sowhich guide in particular and whichsection?

• how have you used them? Can youtell us any stories?

• if there were to be other guides,what topics should they be on?

• have you visited the website? Howcan we improve it?

• is there any thing else you wouldlike to tell us about theImprovement Leaders’ Guides?

Email us now [email protected]

A few additional thoughts aboutthe guides

The guides are based on currentthinking and experience.Be aware that this is constantlychanging. Check updates on theImprovement Leaders’ Guides website,www.modern.nhs.uk/improvementguides, which will be updated oftenas we test out and learn from newtechniques.

Be aware of your own experience.If this field is totally new to you, planhow you can find out more throughfurther reading or developmentcourses. If you are more familiar withleading service improvements, can youshare your experiences andknowledge with others in yourhealthcare community and the wider NHS?

Make contact with others who haveimprovement skills.Many people in healthcare have hadtraining in the improvement skillscontained in these guides. Theirtraining will most likely have been fora particular service such as primarycare, dermatology or cancer. Makecontact with them to form a healthcommunity improvement network tosupport and learn from each other.

Try it for yourself.These guides don’t represent the onlyway to do things, but they provide agood starting point. Create your owncase studies and then share yourexperiences.

Managing the humandimensions of change

Managing the human dimensions of change Managing the human dimensions of change


Contents

1.0 Why is this guide important?

2.0 The process of change2.1 Managing transitions2.2 Change equation

3.0 Frameworks and models to help people through the process of change3.1 ‘What’s in it for me’ framework 3.2 Helping people into their ‘discomfort’ zone3.3 How to recognise differences3.4 Building trust and relationships3.5 Creating rapport3.6 Managing conflict3.7 Communication

4.0 Summary

5.0 Activities to support the human dimensions of change5.1 Valuing the differences5.2 Broken squares

6.0 Frequently asked questions

7.0 Useful reading for more information and ideas

‘Great spirit, grant that I may not criticise my neighbouruntil I have walked a mile in his moccasins.’Ancient Indian proverb

The psychology behind the humandimensions of change is an ever-growing area and there has beenmuch research and theorising on thesubject. This guide has been written

by experienced Improvement Leaderswho are involved in healthcareimprovement initiatives. We have puttogether the models and frameworksthat have helped us while working

‘Anatomicalapproach ofimprovement’

• change is a stepby step process

• it is typicallyinitiated top down

• objectives set inadvance (and setin stone!)

• it goes wrongbecause of poorplanning andproject control

In practice – both approaches ofimprovement are necessary

• you need a plan to set direction but need to be flexible

• top down support is needed forbottom up change

• objectives need to be set and theteam should be congratulated wheneach objective is achieved butimprovement never ends

• correct use of improvement tools and techniques should be plannedand monitored but gaining thecommitment of people is vital

‘Physiologicalapproach ofimprovement’

• outcomes cannot be predetermined

• change comes typically ‘bottom up’

• there is no endpoint

• it goes wrongbecause of peopleissues

Two approaches to improvement

1. Why is this guide important?

Many change projects fail, and the most commonly citedreason is neglect of the human dimensions of change. This neglect often centres around a lack of insight into whypeople resist organisational change, a poor appreciation of theprocess of changing people and a limited knowledge of thetools and techniques that are available to help ImprovementLeaders overcome resistance to change. This guide will helpyou to understand and to better manage these fundamentalaspects of the change management process, and help you toempower, enable and engage those you work with.


• there might be an increase inabsenteeism, sickness and peopleleaving the organisation combinedwith a fall in morale and jobsatisfaction

• people don’t match ‘words withdeeds’, that is, they do not do whatthey say they are going to do

• conflict seems to spiral out ofcontrol

The theme for this guide is to helpyou understand these frequentreactions to change and guide youthrough some models andframeworks to help you respond more successfully to the challenges of managing the human dimensionsof change.

What you as an Improvement Leaderneed to consider is that people havedifferent needs and different styles ofworking especially in a changesituation. It is often the lack ofunderstanding of their needs and alack of recognition of the value oftheir different perspectives that causespeople to be labelled ‘resistant tochange’.

There are no magic wands and noguarantees about how people willreact. What follows are someframeworks that you may find usefuland you might want to investigate inmore depth.




“All models are wrong but someare quite useful.”

W. Edwards Derning

2. The process ofchange

2.1 Managing Transitions

We go through transitions in everydaylife, changes such as getting married,having a baby or buying a new house,some of which are painless and someof which are not! We also help ourpatients with a transition in thegrieving process. So transition is not anew experience to any of us – butthat fact is often forgotten or ignoredwhen changes are introduced inhealthcare organisations.

Transitions can be described in threestages, which are both natural andpredictable.• the ending when:– we acknowledge that there are

things we need to let go of– we recognise that we have lost

something– example: changing your job. Even

when it is your choice, there are stilllosses such as losing close workingfriends

• the neutral zone when:

– the old way has finished but thenew way isn’t here yet

– everything is in flux and it feels likeno one knows what they should bedoing

– things are confusing and disorderly

– example: moving house. The firstfew days or even months aftermoving the new house is not homeyet and things are quite probably inturmoil

• the beginning when:

– the new way feels comfortable, rightand the only way

– example: having a baby. After a fewmonths in the neutral zone ofturmoil, you come to a stage whenyou cannot imagine life withoutyour new baby

“A round man cannot beexpected to fit into a square holeright away. He must have timeto modify his shape.”

Mark Twain

“Change is not the same astransition. Change is situational:the new site, the new structure,the new team, the new role, thenew procedure. Transition is thepsychological process people gothrough to come to terms with the new situation. Remember thatchange is external and transition is internal.”

William Bridges

“They are far less antagonisticnow … I think they have got usedto the idea, and some of them areactually seeing the benefits.”

Local Clinician Cancer ServicesCollaborative

with the wide variety of people inhealthcare. It is a starting point foryou as an Improvement Leader. Formore ideas and information about thistopic look at the Improvement Leaderswebsite for the useful reading section,www.modern.nhs.uk/improvementguides/reading

People and improvementThere are many different approachesto improvement. We have given theterm ‘anatomical approach’ to oneway of thinking, which could bedescribed as the hard projectmanagement approach to change.Another approach, ‘the physiologicalapproach’, focuses much more on thesofter, people side of change. Whatwe have realised is that for asuccessful improvement initiative theImprovement Leader needs toconsider both approaches as shown inthe table on page 9.

When trying to make improvements inhealthcare, gaining the commitmentof the people who are likely to beaffected by the change is paramount.If the people issues are not identifiedand managed effectively, thefollowing problems may arise: • strong emotions, such as fear, anger,

hopelessness and frustration canderail your change project

• people become defensive. Theymight deny there is problem, overemphasise the benefits of thepresent working practice, blame thesystem or blame others within theorganisation

• there is often constant complaining,questioning and scepticism


www.modern.nhs.uk/improvementguides 1312 www.modern.nhs.uk/improvementguides

What we all have in common is thatfor every change, we go through atransition. The difference between usas individuals is the speed at whichwe go through that transition whichcan be affected by a variety of factors.These factors include past experience,personal preferred style, the degree ofinvolvement in recognising theproblem and developing possiblesolutions, and the extent to whichsomeone was pushed towards achange rather than moving towards itvoluntarily. Our advice for you as anImprovement Leader is to help peoplerecognise the process and the stagesof a transition as something that isperfectly natural.

As an Improvement Leader you canhelp transitions by considering thefollowing checklists.

A checklist for managing endings• help everyone to understand the

current problems and why thechange is necessary

• identify who is likely to lose what.Remember that loss of friends andclose working colleagues is just asimportant to some, as status andpower is to others

• losses are very subjective. The thingsone person may really grieve aboutmay mean nothing to someone else.Accept the importance of subjectivelosses. Don’t argue with othersabout how they perceive the lossand don’t be surprised at what youmay consider to be an ‘over reaction’

• expect and accept signs of grievingand acknowledge those lossesopenly and sympathetically

• define what is over and what isn’t.People have to make the break atsome time and trying to cling on toold ways prolongs the difficulties

• treat the past with respect. Peoplehave probably worked extremelyhard in what may have been verydifficult conditions. Recognise thatand show that it is valued

• show how ending something ensuresthe things that really matter arecontinued and improved. Stressingthe change will improve theexperiences and outcomes forpatients are the most importantthings for most healthcare staff

• give people information and do itagain and again and again in avariety of ways. Give people writteninformation to go away and read, aswell as giving people theopportunity to talk to you and askyou questions

• use the ‘What’s in it for me’ modelin section 3.1 to map out how bestto approach different individuals

A checklist for managing theneutral zone• recognise this as a difficult time that

everyone goes through• get people involved and working

together and give them time and

space to experiment by testing new ideas

• help people to feel that they are still valued

• particularly praise someone who had a good idea even if it didn’twork as expected. The Plan, Do,Study, Act (PDSA) model encouragestrying things out and learning fromeach cycle

• give people information and do itagain and again and again in avariety of ways. Make sure you feedback to people the results of theideas being tested and decisionsmade as a result of the study part ofthe PDSA cycle

For more information about PDSAcycles look at the ImprovementLeaders’ Guides to Process Mapping,Analysis and Redesign,www.modern.nhs.uk/improvementguides/process

A checklist for managing a newbeginning• make sure you do not force a

beginning before it’s time.• ensure people know what part they

are to play in the new system• make sure policies, procedures and

priorities do not send out mixedmessages

• plan to celebrate the new beginningand give the credit to those whohave made the change

• give people information and do itagain and again in a variety of ways

For more information read Bridges, W.(1995) Managing transitions: Makingthe most of change, London, NicholasBrearley. [2nd Edition due to bepublished May 2002]

“Most organisations try to startwith a beginning, rather thanfinishing with it. They pay noattention to endings. They do notacknowledge the existence of theneutral zone, and then wonderwhy people have so much difficultywith change.”

William Bridges

2.2 The change equationThere are lots of reasons why peoplemay be hesitant about changing the way they do things. These may include:• having a poor appreciation of the

need to change or considering theneed to change to be secondary toother issues

• having a poor understanding of theproposed solutions or consider thesolution to be inappropriate

• disagreeing how the change shouldbe implemented

• embarrassment about admitting thatwhat they are doing could be improved

• lacking trust in a person or theorganisation, as they believe it hasfailed to successfully implementchange in the past

• anticipating a lack of resources

As an Improvement Leader it would be a good use of your time to reallyunderstand the reason for resistance.Consider whether the person’s apparent resistance stems fromsomething they do not know orunderstand, something they do nothave the capacity or resources to do, orsomething that they consider will leavethem worse off than now.

“People responsible for planning andimplementing change often forgetthat while the first task of changemanagement is to understand thedestination and how to get there, the first task of transitionmanagement is to convince people to leave home. You’ll save yourself alot of grief if you remember that.”

William Bridges



Also consider if they are unaware thattheir behaviour is seen as resisting thechange.

Resistance is a natural, universal,inevitable human response to achange that someone else thinks is agood idea, and resisting change orimprovement does not make someonebad or narrow-minded. We’ve alldone it and our response will be oneof three things: fight, flight or freeze.

You may find the following changeequation a powerful tool. It showsthat we need to recognise andunderstand many factors from theperson’s point of view in order toovercome any resistance.

“I did have a problem with oneconsultant … the first thing I realisedwas that he didn’t understand abooked admission. After that, if Iwent to see consultants aboutbooking, I took a diagram of what abooked admission was. We assumethey understand and they don’t, andthat’s probably part of why they’reresistant to it.”

Regional Office Booked Admissions LeadNational Booking Programme

X X X

dissatisfaction: with the present situation

vision: an understanding of what the change(s) would look like

capacity: sufficient resources to make the change happen

first steps: an appreciation of how the change is to be implemented

Adapted from Beckhard and Harris

If any of the elements on the left-hand side of the equation are zero, therewill be insufficient impetus to overcome the resistance to change.

“The … thing … that wasastounding was mapping. We allthought we knew how the systemworked but none of us had a clue.Many times an hour my mouthwas just falling open because Ididn’t realise what a mess it was.”

Lead Clinician Cancer ServicesCollaborative

VisionAsk the questions• what does this person want for their

patients, themselves and theircolleagues?

• what are their values and beliefs,goals and desires?

• what could the new system look like?

CapacityAsk the questions• what resources are needed to

achieve the change? don’t forgetresources such as energy andcapability

• how can the resources be generatedor shared?

“One of the reasons we gotinvolved was because we careabout the way that we deliver theservice to patients … we wereinterested in ways of trying toimprove … you think, there mustbe a better way of doing things.”

Lead Clinician Cancer ServicesCollaborative

To understand more aboutinvolving patients and carers seewww.modern.nhs.uk/improvementguides/patients

• has this person shown in the past that they are willing to try out newideas? It has been shown time andtime again that it is most effective totest out new improvement ideas withpeople that are willing to try newthings (see page 42)

• is there anyone this person respectsboth professionally and personally and who has demonstrated theenergy and capability to makechanges? Could you put them incontact? Often we are enthused andenergised by others we see as similarto ourselves.

First stepsAsk the question• what first steps could people

undertake which everyone agreeswould be moving in the rightdirection?

To understand more about processmapping and ‘plan, do, study and act’(PDSA) cycles as a means of testing outideas on a very small scale beforeintroducing a change see theImprovement Leaders’ Guide to ProcessMapping, Analysis and Redesign atwww.modern.nhs.uk/improvementguides/process

By working with the left side of theequation people will be pulled towardsa change. Generally, it is better to pullpeople towards a change rather thanpush people into it. People must realisethat the costs and risks of maintainingthe status quo outweigh the risks andthe uncertainty of making the change.Most people who have conductedsuccessful changes stress theimportance of this.

DissatisfactionAsk the questions• how satisfied is the person with the

curent state of things?• is any dissatisfaction shared with

their colleagues?• how is the dissatisfaction

understood and experienced?The change equation

Dis-satisfaction Vision Capacity First

steps Resistance

For more information read Beckhard and Harris (1987): Organisation Transitions: Managing Complex Change, Addison Wesley OD Series




Columna

b & c

d

e

3. Frameworks and models to help peoplethrough the process of change

3.1 ‘What’s in it for me’ (WIFM) framework

A useful way to consider the different needs and attitudesof each individual, or even a group, who are to be keystakeholders in your improvement initiative is to carry out a‘what’s in it for me’ analysis. Try to do this as soon as youbecome involved in the improvement initiative, beforepeople have taken up ‘positions’ and remember to revisit asoften as required.

Keypeople(orgroup)

a

W. I. F. M?(What's In it For Me)

+Impact

b

What could theydo to support or prevent theimprovementinitiative?

d

What could/shouldwe do to reduce non-compliant activitiesand encourage andsupport compliantones?

e

-Risk

c

CommentEnter name or the group (beware Data Protection issues if youname names!) You could have three ‘types’ – those expected tobe for the change, those expected to be against it, and thoseexpected to be neutral or as yet undecided.

In these columns record the positive and negative ideas and commentsthe individual or group are likely to express on hearing about theimprovement idea. Possibly test out your thoughts with others.

WIFM criteria could include:• deep held values and beliefs• working relationships• conditions of work: place, hours etc• salary• job security• nature of work: tasks, responsibilities etc• power, status, position, identityThe more criteria that are negatively affected by the change, thegreater the resistance to change. Changes that negatively interferewith a person’s power, status, position and identity will evoke themost resistance.

Now list the actions the individual or members of the group couldtake to support or resist your initiative. Consider if they show:• commitment: want to make the change happen and will work

to make it happen• apathy: neither in support nor in opposition to the change• non-compliance: do not accept that there are benefits and have

nothing to lose by opposing the change

Think about what you and/or your team could and should do. Youneed to:• move non-compliant people to a position of neutrality, as it is

very difficult to move them to a position of commitment quickly• detect and negate potential non-compliant activities• look for, build on and encourage any supporting behaviourUse the models and frameworks in this guide to ensure youinteract with this group or individual with the best possible effect.People prefer immediate reward as opposed to delayed rewards.So short term wins are very important.

The WIFM chart

How to use the WIFM chart

Peter Weaver Associates



The panic zone is the place many areforced into when confronted with achange that they do not agree with. Itis when people have been forced intothe panic zone that you will mostlikely feel:• stress, worry and fear• anger, irritation and annoyance• sadness, hopelessness and apathy• guilt and shame• inadequacy and frustration

Here people freeze, they certainlydon’t change and they won’t learn.



“… if your consultant staff aren’t on board then it ain’t going to work.Unfortunately, like so many other things in the NHS, they are the lynchpinand if you can’t get them on board … it doesn’t matter what else you do,the project isn’t going to work.”

Regional Office Booked Admissions LeadNational Booking Programme

3.2 Helping people into their‘discomfort zone’

We have all experienced changesituations where we have gone from afeeling of comfortable stability into afeeling of panic. It is useful for anyonein improvement to remember when ithappened to you and understandthose feelings.

The comfort zone is where somepeople are quite happy to stay. It maybe a way of thinking or working, or ajob that someone has been doing fora long time. In a comfort zone: • things feel familiar and certain• the work is controllable and

predictable• people feel comfortable and

competent• there is no threat to self esteem

or identity• there is a sense of belonging

However, in the comfort zone peoplegenerally don’t need to learn newthings and therefore don’t change.

As an Improvement Leader, the beststrategy is to help people out of theircomfort zone but not into a paniczone by encouraging them into thediscomfort zone. It is in the discomfortzone that people are most likely tochange and learn how to do thingsdifferently.

To encourage people to leave thecomfort zone you need to help themfeel ‘safe’.

You can help people to feel safe bycreating the right environment andculture. This will include ensuring thereis no blame, and developing a cultureof mutual support and respect. Thenask them to question the currentsituation and see it from another pointof view such as other members of staff

or the patients and their carers. Two ofthe best ways to do this are describedin detail in other guides in this series forImprovement Leaders: ProcessMapping, Analysis and Redesign –www.modern.nhs.uk/improvementguides/process;and Involving Patients and Carers –www.modern.nhs.uk/improvementguides/patients

Other methods to help people feelsafe include:• create a compelling and positive vision

of how things could be• provide access to appropriate

training and positive role models• provide coaches, feedback and

support groups• ensure systems and structures are

consistent

“It’s change. People are resistantto change... often those peoplehave been in those posts for along time …they like doing thingstheir own way.”

Regional Office Booked AdmissionsLead National Booking Programme

Panic Zone – people freeze, will not change, will not learn

Discomfort Zone – people uncertain, most likely to change, most likely to learn

ComfortZone

Comfort Zone – people stay here, don't change, don't learn

For more information read Senge, P. (2000) The Dance of Change: sustainingmomentum in a learning organisation, Nicholas Brealey

Panic Zone

Discomfort Zone




3.3 How to recognisedifferences

As an Improvement Leader, you needto consider the individuals you will beworking with. Try to understand howthey may react, how best tocommunicate with them and howbest to work in ways that suit them as individuals.Remember to see the person, not aname badge or title.

Personal styles, the key tounderstanding othersPeople tend to relate to the worldaround them in several differentdistinct ways. Four different styles canbe identified as in the table below:Analyst, Amiable, Expressive and Driver.

For more information read MerrillD.W. and Reid R.H. (1999) PersonalStyles and Effective Performance:make your style work for you, CRC Press, London

Matching wavelengthsThe chance of a message being heardand understood would be greatlyimproved if both parties were usingthe same wavelength. If you wantyour message to be understood, youshould try to change your wavelengthto fit the other persons.

Consider what the receiver views asimportant, what some of his/herinterests are and how he/she tends tobehave. With this picture in mind youcan then ‘package’ your message sothat it fits the receiver’s frequency.

Remember that people will not alwaysfit these descriptions of personal style.However, the more a person follows apattern, the more likely adopting acommunication style appropriate tothat pattern will influence them.

Analyst

analyticalcontrolledorderlyprecisedisciplineddeliberatecautiousdiplomaticaccurateconscientiousfact findersystematiclogicalconventional

Amiable

patientloyalsympatheticteam personrelaxedmaturesupportivestableconsiderateempatheticperseveringtrustingcongenial

Expressive

verbalmotivatingenthusiasticgregariousconvincingimpulsivegenerousinfluentialcharmingconfidentinspiringdramaticoptimisticanimated

Driver

action-orientateddecisiveproblem solverdirectassertivedemandingrisk takerforcefulcompetitiveindependentdeterminedresults-orientated

While all four approaches are at the disposal of each and every individual, thereis a tendency for most of us to develop one approach more than the otherthree. We tend to have a main, predominant style, a back up style, and a leastused style.

The predominant approach can be described by:• what the individual finds of interest• what the individual feels is important• his/her behaviour or actions

May be perceived positively as:

• accurate• conscientious• serious• persistent• organised• deliberate• cautious

May be perceivednegatively as

• critical• picky• moralistic• stuffy• stubborn• indecisive

How to work betterwith Analysts

• tell how first• list pros and cons• be accurate and logical• provide evidence• provide deadlines• give them time, don’t

rush or surprise

Style descriptions

The Analyst: Technical specialist

Communicating with an AnalystAnalysts want facts, figures and data in the message. It would help to presentthe message in an orderly fashion, have some documentation to support theviews and be prepared to give the Analyst a chance to examine carefully whatis being sent.

AnalystAnalyst: interested in, and places a highvalue, on facts, figures, data and reason.Others often describe his/her actions, asanalytical, systematic and methodical.He/she tends to follow an orderlyapproach in tackling a task and is wellorganised and thorough in whateverhe/she does. Others may see him attimes as being too cautious, overlystructured, someone who does thingstoo much ‘by the book’. He/she analysespast data, considers the present situationand projects these facts. He/she viewstime in a linear or sequential fashion.

Written communication An Analyst’s style:• quite formal and precise• list key points • may use an outline style, with

subheadings and numbered sections• include tables and appendices • often contain facts and figures in

their messages




AmiableAmiable: interested in and places highvalue on personal relationships,feelings, human interactions andaffiliation with others. Often describedas a warm person and sensitive to thefeelings of others. He/she appears tobe perceptive, able to assess asituation in terms of the humanemotions involved and is oftenconsidered a loyal and supportivefriend. At other times he/she may beviewed as too emotional, sentimentaland too easily swayed by others.He/she often makes reference to pastevents and his/her relationships withothers over a period of time.

Communicating with an AmiableFor Amiables make sure you includethe human dimensions of thesituation. He/she will want to knowhow others may feel about the matter,who else will be involved in it, pastexperience in similar situations etc.

Written communication The Amiable’s style is often moreinformal, chatty and friendly. He/shemay inject names and makereferences to others and to pastevents.

ExpressiveExpressive: interested in taking peoplewith them, enthusing them withoptimism and energy. He/she will beopen with people and willing to makepersonal investment and so they aregenerally very good with people.However he/she can frighten peopleby being over-dominant and can feelpersonally let down by people and leftout. They tend to be poor with detailand their hunches can go wrong.

Communicating with an ExpressiveBear in mind that he/she will belooking for the new, the exciting andthe innovative aspects of the message.


The Amiable: Relationship specialist

May be perceivednegatively as:

• hesitant• ‘wishy washy’• pliant• conforming• dependent• unsure• laid back

How to work better with‘Amiables’

• tell why and who first• ask instead of telling• draw out their opinions• explore personal life• define expectations• strive for harmony

May be perceivedpositively as:

• patient• respectful• willing• agreeable• dependable• concerned• relaxed• organised• mature• empathetic


• verbal• inspiring• ambitious• enthusiastic• energetic• confident• friendly• influential


• a talker• overly dramatic• impulsive• undisciplined• excitable• egotistical• flaky• manipulating

How to work betterwith Expressives

• tell who first• be enthusiastic • allow for fun• support their creativity

and intuition• talk about people

and goals• handle the details

for them• value feelings and

opinions• keep fast paced and

be flexible

Written communication Written communication from anExpressive can tend to be rather vagueand abstract. They are inclined to beidea-orientated and are often quitelengthy in making a point.

DriverDriver: place great emphasis on actionand results. Often viewed as decisive,direct and pragmatic. His/her timeorientation is here and now. He/shelikes to get things done and hatesspinning things out. He/she translatesideas into action and is dynamic andresourceful. He/she may be accused oflooking only at the short term and

neglecting long-range implications.This same tendency sometimesexposes him/her to criticism fromothers who may see him/her as tooimpulsive, simplistic, acting beforehe/she thinks.

Communicating with DriversDrivers will want to know ‘what arewe going to do?’ and ‘how soon canwe do it?’

Written communicationDrivers’ writing is inclined to be brief,crisp and sketchy, resents having totake the time to write and will oftenscribble a brief reply on the sender’soriginal message and return it to him.

The Expressive: Social specialist

Using personal styles whenworking with individuals andgroupsWhen working with someone, it isimportant to consider his or her needsand styles. You also need to be awareof your own style and biases and tryto understand and relate to thosewho may have styles that are differentto yours.

Working with individualsAs an Improvement Leader you mayneed to have a discussion withsomeone about a possibleimprovement suggestion. In yourpreparation for the meeting askyourself the following questions:

• would this person prefer a face toface explanation or would theyprefer to have a paper to readthrough first?

• would this person prefer specificinformation and supporting data orwould they prefer to know what theimplications are?

• would this person prefer the logicalexplanation with a cause and effectanalysis and a clear options appraisalbased on facts, or would they preferto know the values behind the

We would suggest you prepare for allstyles but listen for clues and focus onindividual styles.

Working with a groupIt would be good if you had the timeto talk to everyone as an individualbut this is rare. However, you canapply the thinking about personalstyles when you work with a smallgroup of just two or three people in ameeting or a larger group at an event.





Case study This model was introduced to a group of Cancer Services Collaborativeproject managers. One project manager had no difficulty in recognising herstyle as a Driver. She also recognised the style of someone who she felt shewas having ‘difficulty’ with – an Analyst. When she returned to work shechanged the way she dealt with this person giving them more written factsand figures and time to think through the information and she tried to beless ‘pushy’. She reported back a few weeks later that the ‘difficult’ personwas totally on board with the programme and a real supporter.

Exercise:• when you have written a memo

or prepared a presentation,show it to a colleague who youtrust and has a different stylefrom you

• ask what they would change tomake it more effective for them

thinking and the effect it might haveon the staff and patients?

• would this person prefer to have aclear agreed project plan withmilestones or will they prefer to takea flexible approach?

Case study An Improvement Leader (Driver)was keen to bring about a changeto reduce waiting times forpatients. However, she initiallyfailed to realise that the list of prosand cons was not sufficient toconvince her Amiable colleague.Her colleague needed to feelconvinced that it was a realimprovement from the patients’point of view.


• decisive• independent• practical• determined• efficient• assertive• a risk taker• direct• a problem solver


• pushy• one man/woman show• tough• demanding• dominating• an agitator• cuts corners• insensitive

How to work betterwith Drivers

• tell what and whenfirst

• keep fast paced• don’t waste time• be businesslike• give some freedom• talk results• find shortcuts

Driver: Command specialist


3.4 Building trust andrelationshipsIf you have a good relationship andmutual trust between yourself andthose you are working with, you aremore likely to find them receptive tothe new ways of thinking and theimprovement methods you want tointroduce.

What is trust?Trust requires two things:competency and caring. Competency



You should prepare to relate to allstyles by including:• time for interactions and discussion

as well as time for reflection• sufficient details and evidence to

support your case as well as anindication of the possibilities

• the logic behind the thinking andthe impact on people

• a proposed plan with milestones butone that also allows flexibility

Before the event• make sure all necessary information

is sent out to participants in plentyof time before any meeting or event

• include the start and finish times,day, date, place, any preparation theparticipants need to do and theobjectives for the meeting or event

• don’t forget to include a contactname and contact details for anyquestions

During the event:• agree objectives and ground rules at

the start. Ground rules could includeallowing everyone the opportunityto participate, being honest andopen, ensuring confidentiality withinthe group etc

• set timeframes for the start and endof the event and for lunch andcoffee breaks, but allow flexibility inthe agenda between those times

• use the flip chart as a ‘car park’ forideas, issues and thoughts, whichdeviate from the agreed objectivesof the session. If a group getsfixated on the details – for example,when mapping the patient journey –agree to ‘park’ the issue and move


on. You can return to these issueslater in the day, or at subsequentevents

• summarise and agree deadlines,actions or next steps together. Agree a deadline for notes from the meeting to be sent out. Includeactions around the ideas, issues andthoughts that were noted on the flip chart

• consider ways of working that takethe different styles into account, forexample:

– have back-up data and informationavailable for those who want it, butdon’t go into too much detail withthe whole group

– if you need to generate ideas orgain information from theparticipants, ask them to think bythemselves for a few minutes andwrite down their thoughts beforehaving a group discussion

After the event:• make sure that the notes are

circulated within the agreed timeand that agreed actions arefollowed up

Affection

Distrust

Trust

Respect

Extent to which I believe you are competent and capable

Low High

High

Low

Extent to whichI believe you

care about me

alone or caring by itself will notcreate trust. This model, illustratedbelow, says that if I think someone iscompetent, but I do not think theycare about me, or the things that areimportant to me, I will respect thembut not necessarily trust them. Onthe other hand, if I think someonecares about me but I do not feelthey are competent or capable, I willhave affection for that person butnot necessarily trust them to do thejob in hand.

For more information read Scholtes P (1998) The Leaders Handbook, makingthings happen getting things done, McGraw Hill.

Building trust

Adapted from P Scholtes.





Trust and relationshipsYou can encourage people to trustyou if you:• do what you say you will do and do

not make promises you can’t orwon’t keep

• listen to people carefully and tellthem what you think they aresaying. People trust others whenthey believe they understand them

• understand what matters to people.People trust those who are lookingout for their best interests

You can encourage good relationshipswith people if you:• are able to talk to each other and

are willing to listen to each other• respect each other and know how

to show respect in ways the otherperson wants

• know each other well enough tounderstand and respect the otherperson’s values and beliefs

• are honest and do not hide yourshortcomings. This may improveyour image but does not build trust

• don’t confuse trustworthiness withfriendship. Trust does notautomatically come with friendship

• tell the truth!

3.5 Creating rapportAs an Improvement Leader, it is vitalto communicate and work with othersin ways that suit them. Remembercommunication is 7% words, 38%tone of the voice and 55% bodylanguage. When you have a goodfeeling with someone you probablyhave rapport.

Building rapport is a techniquedescribed and practised in NeuroLinguistic Programming (NLP), which isthe study of what works in thinking,language and behaviour.

What is rapport?Rapport is the process of building andsustaining a relationship of mutualtrust and understanding. It is theability to relate to others, in a waythat makes people feel at their ease.When you have rapport with someoneyou feel at ease, conversation flowsand silences are easy. It is the basis ofgood communication and is a form ofinfluence. It is a major component oflistening, when the whole bodyindicates interest in what the otherperson is saying.

Creating rapportFirst you have to be aware of yourself.Then make a conscious effort tomatch as many of the other person’scharacteristics as possible:• posture

look at and match the position ofthe body, legs, arms, hands andfingers, and how the head andshoulders are held

• expressionnotice and match the direction ofthe look and movement of the eyes.Ensure you make and keep eyecontact

“It’s not what you say, it’s the waythat you say it.”

Louis Armstrong

• breathingmatch the way the other person isbreathing. People will breathe eitherfast or slow, from their chest or their abdomen

• movementnotice if their movements are fast orslow, steady or erratic. Make yourmovements the same

• voicethink about the pace, volume, andintonation of their voice. Listen tothe type of words being used. Try to use a similar voice and words

Rapport, pacing and leadingPacing is about respecting the feelingsor style of others. If someone isfeeling anxious, to pace him or her isto show an understanding of thatanxiety. If someone is having fun, to

pace him or her is to join in the fun.When we talk about someone’sexcitement or enthusiasm beinginfectious, we are really talking aboutour ability to pace and join in.

When you can match and pace youcan also, with practice, lead andinfluence. You might lead from asubdued lethargic mood into anexciting energetic mood, or lead fromspeaking quietly to speaking loudly.

You might want to use matching,pacing and leading with individuals or groups:• when someone is angry, to help

calm them down• when someone is tense, to help

them relax• when things feel slow, to speed

them up and create a feeling of energy

But this should be done sensitively,using discretion and great care.

3.6 Managing conflictConflict is a reality of improvementand cannot be avoided but it can bemanaged and it can turn out to bevery positive. An organisation thatwas operated completely bycomputers or robots without anypeople would never experience thestresses and detrimental effects ofconflict. However that organisationwould not remain in business for verylong, as it would never grow anddevelop.

Exercise:Next time you are in a meeting orwith a group of people, payattention to the elements ofrapport: posture, expression,breathing, movement and voice.Notice the posture and movementsof yourself and others in the group.Listen to the words and voices.• identify who appears to be in

rapport with others in the group• look for mismatching if some

people are not getting on so wellor are disagreeing

If it is comfortable to do so, speaklater with the participants youobserved. Ask how they werefinding the discussions, how theyfelt and check whether theirresponses match your observations.





Conflict can be defined as “whenbehaviour is intended to obstruct theachievement of some other person’sgoals.” D Coon

For more information read Coon, D(1992) Introduction to Psychology –exploration and application, WestPublishing Co. USA

Conflict can range from a minormisunderstanding, to behaviour whereeach party only seeks to destroy theother. Generally conflicts have twoelements:• the relationship between the people

involved • the issue which is the basis of the

disagreement

As an Improvement Leader, youshould be able to intervene effectivelyin the early stages of conflict bypreventing, containing or handlingeven if you are involved in the conflictyourself:• preventing escalation by identifying

early signs and taking action• containing to stop it worsening by

dealing with difficulties and tensionsand working to re-establishrelationships

• handling by taking positive steps todeal with the conflict issues andmonitoring the effects

If the conflict gets worse, you willprobably need someone else to helpthe parties involved in the conflictdevelop longer-term strategies.

Preventing conflict from escalating Conflicts will take on a life of their

own and will get worse if left alone,so ask yourself the followingquestions about any conflict as soonas it becomes apparent to try to stopit escalating.• what type of conflict is it?– hot conflict where each party is

keen to meet and discuss to thrashthings out

– cold conflict where things are keptquiet and under the surface

• what are the most importantunderlying influences at work?

• what is this really all about?• where is the conflict going?• how can I stop it?• what needs to happen now?

Containing conflictRemember that conflicts are moreabout people than problems, sounderstand and value the differencesin the parties involved, which mayinclude yourself.• recognise your own style with its

strengths and its limitations• listen and try to understand the

other person instead of attributing amotive from your viewpoint

• ask questions to develop yourunderstanding of the goal from theother person’s point of view

• look for a solution that incorporatesboth goals

Do

• work to cool down the debate ina hot conflict

• convince parties in a cold conflictthat something can be done

• ensure that the issues are fullyoutlined

• acknowledge emotions anddifferent styles

• make sure you have acomfortable environment for any meeting

• set a time frame for thediscussion

• ensure good rapport• use names and, if appropriate,

titles throughout

Don’t

• conduct your conversation in apublic place

• leave the discussion open – createan action plan

• finish their sentence for them• use jargon• constantly interrupt• do something else whilst trying to

listen• distort the truth• use inappropriate humour

Conflict means different things todifferent people. This may be due totheir personal style or even theirprofessional training. • some people can find a heated

discussion stimulating and enjoy a‘good argument’ whilst others canbe torn apart by it. Just becausesomeone asks you lots of pointedquestions or disagrees with you in ameeting does not mean that theyare against you or the objectives ofthe project. It may just be their wayof gathering further information tothink about later

• remember also that doctors andscientists in general are trainedto challenge information,concepts and ideas. They may betesting out the validity of theproject and your knowledge. Wehave found over and over againthat direct questioning does notmean that people are against theproposal

The main thing is to acknowledgeany conflict and not to avoid it.Describe the issues involved, talkabout it and work through it.

Conflict when managed properlycan be ‘an energising and vitalisingforce in groups and in theorganisation.’

Fitchie & Leary

Handling conflictThe following checklist of do’s anddon’ts may be useful at any stage of a conflict situation.

For more information read Fitchie R. andLeary M. (1998) Resolving conflicts inorganisations, Lemos & Crane

General tips for goodcommunication• uncertainty is more painful than

bad news, so communicate earlyand often

• seek first to understand and then tobe understood

• communicate directly with thepeople that matter using multiplemedia, but preferably face-to-face

• make the communication processtransparent and two-way

• be honest and tell the truth• the result of a communication is the

response you get, which may bedifferent from what you intended

• you will always be communicating,even when you think you’re not – aperson cannot not communicate,and behaviour is the highest form ofcommunication

Exploring Exploring is the use of questions andthe encouragement to open up andenlarge your understanding of issuesfrom others. The aim is to exploreresponsively rather than tointerrogate, so use questions thatencourage the other person todescribe information and feelings of significance.• follow the speaker’s direction: ‘tell me

more about that…’, ‘what happenedthen..’, ‘is there anything else..’

• avoid ‘why’ questions as they oftencreate defensive responses, insteaduse what, how and when

Active listening Active listening is listening to others inorder to understand their ideas,opinions and feelings and todemonstrate actively to the person

that you have understood their ideas,opinions and feelings.• give the speaker your full attention

and build rapport (see section 3.5)• reflect back using the speaker’s

words, either in a pause orinterrupting with permission: ‘can I just check that I’ve understoodthese points?’

• reflect back any feelings behind thewords you may have become awareof, by re-stating them: ‘it sounds asif you are frustrated by this’, ‘itsounds as if that was a very excitingopportunity for you’

• summarise and clarify what youhave heard after several reflectionsto check your understanding of thewhole topic

• when you are sure you havecompletely understood the otherperson’s ideas, opinions andfeelings, you can interpret with ‘itsounds as if you intend to…’ or ‘itsounds as though you would preferto…’. However, be prepared for a negative reaction if the speakerperceives you are distorting what they have said to suit yourown agenda

Benefits of active listening• the speaker feels understood, has

opportunities to express thoughtsmore concisely and opportunities tocorrect misunderstandings

• being listened to helps people off-load and gets rid of things thatblock future thinking and action

• the listener has to suspend theirown opinions and own agenda andfollow the direction of the speakers.This means giving up on solving theother person’s problems for them





Case study There was an agreement to decide a set of referral criteria for patients withsuspected cancer. Each of the consultants involved currently applied differentclinical practice and different thresholds for deciding whether or not a patientwas high risk. The discussions lasted for several weeks and were characterisedby one consultant quoting research findings only to be challenged by anotherusing anecdotal evidence and a third acting as devil’s advocate posing many‘what if’ scenarios. The Improvement Project Manager managed the situation in a number ofways. These included summarising where there seemed to be agreement andbringing examples of criteria set by other hospitals both to stimulatediscussion and to foster an environment of wider collaboration. The team of consultants eventually agreed on a set of criteria and went on todemonstrate their ownership and agreement by collectively defending theirdecisions at a National Conference, in the face of intense questioning fromtheir peers.When asked about the process, the consultants commented that they hadnever had such an in depth argument about clinical practice and they hadfound it invigorating. They said that it had set the tone for frank discussions in other meetings and the ‘conflict’ had kept them hooked on the project.

3.7 CommunicationConflict and communication areinseparable. Communication cancause conflict: it’s a way to expressconflict and it’s a way to either resolveit or perpetuate it. It is very often abreakdown in communication, or

interpretation of that communication,that will inflame the conflict situationand facilitate. So it’s worth taking abit of time to summarise the lessonsabout communication, although thesewill probably not be new to you.

Managing the human dimensions of changeManaging the human dimensions of change


• listening and valuing another’s pointof view opens you up to beinginfluenced by that point of view andyou are more likely to reach a win-win outcome

Communication do’sBefore a meeting• prepare well for any meeting even

with one person• research the issues and the

background• adjust your approach depending on

the person and outcome you aretrying to achieve

• recognise the pressures of the otherperson and the difficulties they mayface in prioritising their actions

During the meeting• be clear and concise• engage in active listening • keep a clear mind• respond don’t react• provide credible information and a

range of solutions or options

Communication don’ts• try to be invisible by communication

through emails only• avoid the issue • have preconceptions about the

other person• over-use jargon, theory or complex

ideas• start from a fixed position that you

are determined to defend at all costs• preach to people• get excited with shouting and finger

jabbing• do more talking than listening or

interrupt the other person with yourown point of view

• try and score points

Rule of threeIf you are unsure about how toprepare for a meeting there is a verygood rule of three, which you mayfind useful. Listen to public speakers –they use it all the time.

3 stages in a meeting

• connect • convince • conclude

convincing

• must do• should do • could do

informing

• topic 1• topic 2• topic 3

persuading

• state the position• identify the problems• present the possibilities

4. Summary


Rule of three

Here is a checklist for you as anImprovement Leader to manage thehuman dimension of change byworking with individuals moreeffectively. Do you:• put your main effort into trying to

understand the other person? Everyperson is unique – respect the otherperson’s view of the world

• develop a range of styles forworking with others? Don’t just relyon one or two ways

• ask open questions, listen carefullyto the answers and show you arelistening by using active listeningskills?

• create a real rapport with the otherperson with the appropriate nonverbal communication?

• ask for feedback? Are you aware ofyourself and how you appear toothers, are you willing to be flexible,to learn and keep changing whatyou are doing until you achieve theresults you want?

• understand that every behaviour isuseful in some way? Behaviour isthe most important informationabout a person, but people are nottheir behaviours

• remember that if you always dowhat you’ve always done, you willalways get what you have always got?

Goldratt, in his book Theory ofConstraints, spends quite a bit of timein the early pages talking about theprocess of change. What he says fitsthe thinking of this guide, the wholeseries of guides for ImprovementLeaders, and our suggestions to you.

We have summarised this on a tableon the next page.

Before organising any activity, considerthe following:• who is the audience?• what is their prior knowledge?• is the location and timing of the

activity correct?• recognise and value that participants

will want to work and learn indifferent ways. Try to provideinformation and activities to suit alllearning styles

Why is this important?Some of us take to the idea of changemore easily than others. Some like todevelop ideas though activities anddiscussions, while others prefer tohave time to think by themselves. Weare all different and need to be valuedfor our differences. The previoussections of this guide have given ideasof how to ensure the best possibleoutcome for working with differentpeople.

5.1 Valuing the differences

Objective• to demonstrate differences in people

Benefits• easy and quick with observable

results• warning: you, as the facilitator, need

to be familiar with the differentstyles in order to answer questions

Time required• 5 minutes to explain the four

different styles• 5 minutes for the participants to

work in their groups • 5 minutes to feed back and draw

out learning

Preparation• four flip charts in four corners of the

room clearly labelled Driver,Analytical, Expressive and Amiable

Overhead slide to describe different styles

For more information read Goldratt E (1990) Theory of Constraints,North River Press, Massachusetts.





5. Activities to support human dimensions of change

Analytical• formal• measured and systematic• seek accuracy/precision• dislike unpredictability and surprise

Amiable• conforming• less rushed and easy going• seeks appreciation between others• dislike insensitivity and impatience

Driver• business like• fast and decisive• seek control• dislike inefficiency and indecision

Expressive• flamboyant• fast and spontaneous• seek recognition• dislike routine and boredom

Goldratt says

• any improvement is a change

• not every change isan improvement

• but we cannotimprove anythingunless we change it

• any change is a perceived threat to security

• there will always besomeone who willlook at the suggestedchange as a threat

• any threat to securitygives rise toemotional resistance

• you can rarely over-come emotional resis-tance with logic alone

• emotional resistancecan only be overcomeby a strongeremotion

As an ImprovementLeader, we suggestyou:

• help everyone to seeand understand thecurrent process

• involve patients andcarers in redesign and help the staff toknow their views andconcerns

• set aims andmeasures to ensurethat all implementedchanges do makeimprovements

• set up systems tomake sure that anyimprovement youmake is sustained

• understand what isimportant toindividuals andgroups

• use the ‘what’s in it for me’ framework

• recognise andunderstanddifferences in howpeople react, likeinformation, makedecisions etc

• develop flexible waysto relate to and buildrapport with differentpeople

Refer to previous sections inthis or other ImprovementLeaders’ Guides

• process mapping analysisand redesign:www.modern.nhs.uk/improvementguides/process

• matching capacity and demand:www.modern.nhs.uk/improvementguides/capacity

• involving patients and carers:www.modern.nhs.uk/improvementguides/patients

• measuring for improvement:www.modern.nhs.uk/improvementguides/measurement

• sustainability and spread:www.modern.nhs.uk/improvementguides/sustainability

• change equation, section 2.2

• what’s in it for meframework, section 3.1

• helping people into theirdiscomfort zone, section 3.2

• how to recognisedifferences, section 3.3

• building trust andrelationships, section 3.4

• creating rapport, section 3.5

• managing conflict, section 3.6• communication, section 3.7

– look for interactions– if the rules are broken, the observer

can destroy all the completedsquares and put all the pieces backin the middle of the table

4. participants empty out the bits ofthe squares in the envelope in frontof them

5. tell the participants to begin tobuild the 5 squares of equal size

Learning pointsAfter the exercise ask the team andobservers to reflect and consider thefollowing questions• how did you feel as an individual?• what were the different

interactions?• what caused the frustrations?• how did you feel as a team?• are there any similarities to people

and departments in healthcareorganisations?

Common themes that oftenemerge• the need to give something up to

benefit the whole team (ororganisation)

• being able to see what needs to bedone but not being allowed to say

• not wanting to ‘play’, if you don’tsee the reason or understand thebenefit

• common frustrations expressed– some want to take control and

direct– some want time to sit back and

think– some want to see what happens

before getting involved– some find it difficult as they need to

talk, talk, talk



5.2 Broken squares

Objective• Interactive demonstration of

working as a team and recognisingdifferences in people

Benefits • easy to do

Time required• total time 30 minutes– 5 minutes introduction• 5-10 minutes exercise – 15 minutes reflection and discussion

Preparation• prepare table packs of ‘broken

squares’ – see page 40• organise into teams of 5 at a table

with one table pack of brokensquares on each table

• open table pack, take out the 5envelopes and give each of the 5participants one envelope of bits

• extra participants should take therole of observers

Instructions to participants1. explain the aim of exercise – to build 5 squares of equal size

out of the broken squares2. explain the rules of the exercise for

the 5 team members– no verbal contact– no pointing and no placing, even

though they may know where apiece of the square should go

– you can place parts of the brokensquares into middle of the table forsomeone else to use

3. explain the rules of the exercise forthe observers

• describe the four different stylesusing an overhead such as the oneon page 37

• emphasise – there is no style which is right or

wrong, no style which is good orbad – there are just different styles

– it is not about ‘putting people intoboxes’ and that we all can workwith all the four styles but wenormally have a preferred stylewhere we feel most comfortable

– no-one is being forced and if anyone does not feel comfortable it isfine to sit and watch

– ask participants to go and stand bythe flip chart they think bestdescribes their personal style

Instructions to participants• consider the following two

questions:– how do you behave under stress?– what are your fears about change?• write their comments on the flip

chart• you as facilitator feed back

comments from each of the fourgroups to the whole group

Learning points• people have very different reactions

to change• possible discussion about the

problems and strengths of ‘stylealike’ or ‘style different’ teams

Valuing the differences variation: Persuading and influencing

Preparation• participants to work in style alike

groups (see previous activity)

Time required• 10 minutes for initial work in type

alike groups• 10 minutes for sharing with

opposite group• 10 minutes for preparation of

presentations• 20-30 minutes for presentations and

discussion

Instructions to participants• consider the question– what would people need to say

to persuade/convince you tochange/buy a new car/house (if appropriate ask the groups to consider a change initiative, eg booked appointments)

• ask the groups to share with theiropposite group, ie Amiables withDrivers, Expressives with Analyticals

• each group then prepares a shortpresentation of what they consideris needed to convince the oppositegroup to change

• each group gives the presentationand receives constructive feed back

• general discussion about persuadingand influencing





Preparation of a broken squaretable pack• take 5 equal squares approximate

size 25cms x 25cms• cut each square into three making

sure that no two parts are the same,as in the suggested patterns above

• mix up all the parts and divide the15 parts unequally into 5 envelopese.g.

– 2 parts in 2 envelopes– 3 parts in 1 envelope– 4 parts in 2 envelopes• put the five envelopes of bits into

one large envelope – the table pack• NB keep a copy of the ‘answer’

handy as at least one team usuallywant help to make up their squares



Suggested patterns for broken squares

QuestionDo the style frameworks describedrelate to patients and carers as well?

AnswerThey certainly do. They relate toeveryone — patients, their carers andeven your family and friends.

QuestionIt sounds to me that some of this isabout putting people into boxes and Iam uncomfortable with this.

AnswerIt is not about putting people intoboxes but about recognising andworking with the styles we all have.Everyone has access to all the differentelements in all the frameworks and willuse them at some time but not withequal ease, comfort and confidence.The key to managing the humandimensions of improvement is to makethe best links with each individual, talktheir language and present informationin the best way for them.

QuestionHow do you turn negative people intopositive people?

Answer:You do not need to. ‘Negative’ peopleare very important in any changeproject because they act as the ‘devil’sadvocate’, they are careful and cautious,they are the ones that will point out the

risks that must be considered. You needto try and bring these people to aposition whereby they are not activelyresisting the change but feel valued fortheir cautious, logical thinking.

QuestionThis guide has concentrated onindividuals. What about when anindividual is ready and willing to changebut the group they closely associatewith is not?

AnswerYou are right and group dynamics is awhole new question and beyond thescope of this guide. However youcould use some of the frameworksdescribed in this guide and otherImprovement Leaders’ Guides toeither work with the individual or thewhole group.• use the change equation and WIFM

framework to tailor the change to the‘willing’ individual for at least onePDSA cycle

• plan to spread the practice of the‘willing’ individual to the group theyclosely associate with

• plan an intervention at the group levelsuch as process mapping to engagethe whole group; seewww.modern.nhs.uk/improvementguides/process

It really depends on the power andposition of the individual who wants tochange and the make up and maturityof the group.

6. Frequently asked questions and answers

TipPractise these activities on friendlygroups to test them out and giveyou confidence.



1. Toolkits These have been developed by nationaland regional programmes for staffaddressing the issues for one particularaspect of care. This can range fromgeneral workforce planning issues toaddressing the problems of a particularservice, e.g. mental health, endoscopyor orthopaedics. They are written forclinical staff in the specific service andwill give you many more change ideas,lots of case studies, national contactnames and information on how toaccess up-to-date improvement activityin that particular area or service.

Usewhen you have identified a problemassociated with a particular service.

2. Books, papers and articlesThese have been written byinternational experts in their fieldaddressing the science and theorybehind many of the tried and testedtools and techniques in the guides.

Usewhen you want a deeperunderstanding in any of the topics.

3. Websites Time is precious and the World WideWeb is vast. Therefore, we want toguide you to the selected websitesdesigned to extend your knowledgeand thinking on improvement theory.

Usewhen you want to extend your general knowledge and gain access to improvement thinking around the world.

So visit the Improvement Leaders’Guide website for the useful readingsection at www.modern.nhs.uk/improvementguides/reading This willbe continuously updated as neweditions are published and you tell uswhat you find useful.



QuestionThere are a thousand people in myorganisation. How do I get them allon board?

AnswerYou do not need to target everyonestraight away. Focus your effortsinitially on the people who want totest out new ideas and want tochange to make improvements. In themodel above by Rogers, these are thegroups called Innovators and the EarlyAdopters. Research suggests that ifyou engage 20% of a population therest will follow but it will take a bit oftime. The ‘laggard’ in this model issomeone who has not yet seen aneed for the change or they do notbelieve the idea on offer will meet

their need. Remember also thatsomeone who is a ‘laggard’ on onenew idea may be an ‘early adopter’ ofa different idea.

For more information about spreadingimprovements, see the ImprovementLeaders’ Guide to Sustainability andSpread at www.modern.nhs.uk/improvementguides/sustainability

Earlymajority

Latemajority

LaggardsInnovatorsEarly

adopters

START HERE

Adopter categories

For more information read Rogers E, (1985), Diffusion of Innovations, The Free Press, New York

7. Useful reading for more information and ideas

Much has been written about improvement and change. So much so that it is very easy to get overwhelmed by allthe material. So we’ve gathered together the things thatwe think you might find most useful. We would like toguide you in three directions:

managing the human dimensions of change: working with ... · managing the human dimensions of...

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