school of health care radicals

@HelenBevan #SHCR #QF15

Supported by


So...................

What lights the “fire in your belly” and makes you determined to improve things?


The genesis of the School

2002

20142013

2010 2012

2003

NHS Change Day 2013

“A school for healthcare radicals”

Applying social movement

thinking to healthcare

improvement

“The School for Health and Care

Radicals”

“A one day school for organisational

radicals”

Applying community organising

principles to healthcare

improvement

2015


Source: @NHSChangeDay


“New truths begin as heresies” (Huxley, defending Darwin’s theory of natural selection)

Source of image: installation by the artist Adam Katzwww.thisiscolossal.com

Via @NeilPerkin

http://www.thisiscolossal.com/


Starts on the fringe

(at the edge)

Starts with the activistsGary Hamel

always


So why do we keep reinventing the past

and calling it the future?

Image used under Creative Commons licence: Kicki


Tomorrow belongs to those who can hear it coming

David Bowie

“ “


SEISMIC SHIFTS


SEISMIC SHIFTS

Change from the edge


Leading change in a new era

Dominant approach Emerging direction




Most healthcare transformation

efforts are driven from this side

@HelenBevan #SHCR #QF15Source: Gary Hamel

@HelenBevan #SHCR #QF15Source:@Alfacarlo


John Kotter, the most influential thought leader globally, recognises new approaches are needed

FROM


John Kotter: “Accelerate!”

• We won’t create big change through hierarchy on its own

• We need hierarchy AND network

• Many change agents, not just a few, with many acts of leadership

• At least 50% buy-in required

• Changing our mindset

• From “have to” to “want to”

TO


From “have to” to “want to”

Source of image s:www.slideshare.net/mexicanwave/champions-trolls-10-years-of-the-cipd-online-community


Managers know how to command obedience and diligence, but most are

clueless when it comes to galvanizing the sort of volunteerism that animates life on

the social web. Initiative, imagination and passion can’t be commanded—they’re gifts.

Gary Hamel http://www.mixmashup.org/blog/reinventing-

management-mashup-architecture-ideology

‘

http://www.mixmashup.org/blog/reinventing-management-mashup-architecture-ideology


The Network Secrets of Great Change AgentsJulie Battilana &Tiziana Casciaro

1. As a change agent, my centrality in the informal network is more important than my position in the formal hierarchy

2. If you want to create small scale change, work through a cohesive network

If you want to create big change, create

bridge networks between disconnected groups


People who are highly connected have twice as much power to

influence change as people with hierarchical power

Leandro Herrero

http://t.co/Du6zCbrDBC

http://t.co/Du6zCbrDBC


DiscussionWhat are the implications of the “emerging direction” for the way

change agents work?


is the new normal!

“By questioning existing ideas, by opening new fields for action, change

agents actually help organisations survive and adapt to the 21st Century.”

Céline SchillingerImage by neilperkin.typepad.com


We need rebels!

•The principal champion of a change initiative, cause or action

•Rebels don’t wait for permission to lead, innovate, strategise

•They are responsible; they do what is right

•They name things that others don’t see yet

•They point to new horizons

•Without rebels, the storyline never changes

Source : @PeterVan http://t.co/6CQtA4wUv1

http://t.co/6CQtA4wUv1

@helenbevan

What happens to heretics/radicals/rebels/mavericks

in organisations?

@helenbevan

@helenbevan #IQTGOLD#NHSChangeDaySource: Lois Kelly http://www.slideshare.net/Foghound/rocking-the-boat-without-falling-out

@HelenBevan

Ostracism is experienced in the brain as deeply as physical pain

@helenbevan

We need to be boatrockers!

• Walk the fine line between difference and fit, inside and outside, rock the boat but manage to stay in it

• Able to challenge the status quo when we see that there could be a better way

• Conform AND rebel

• Capable of working with others to create success NOT a destructive troublemaker Source: Debra Meyerson

@helenbevan

What are the risks for a boat rocker?

1. Our experiences of “being different” can be fundamentally disempowering. This can lead us to conform because we see no other choice

Source: adapted from Debra E Meyerson

@helenbevan



we surrender a part of ourselves, and silence our commitment, in order to survive


@helenbevan

@helenbevan




2. leave the organisation


@helenbevan





we cannot find a way to be true to our values and commitments and still survive


@helenbevan






3. stridently challenge the status quo in a manner which is increasingly radical and self-defeating


@helenbevan






3. stridently challenge the status quo in a manner which is increasingly radical and self-defeating

this just confirms what we already know – that we don’t belong Source: adapted from Debra E Meyerson

@helenbevan#NHSChangeDay #SHCRchatSource : Lois Kelly www.foghound.com

There’s a big difference between a rebel and a troublemaker

Rebel

http://www.foghound.com/

@helenbevan

Reflection• What are your insights around “rebels” and

“troublemakers”?

• What moves people from being “rebel” to “troublemaker”?

• How do we protect against this?

@helenbevan#NHSChangeDay #SHCRchatSource : Lois Kelly www.rebelsatwork.com

There’s a big difference between a rebel and a troublemaker

Rebel

http://www.rebelsatwork.com/

@helenbevan

Change starts with me

Source of image: jasonkeath.com

@helenbevan#SHCR @School4Radicals

"There’s only one corner of the

universe you can be certain of

improving, and that’s your own

self." Aldous Huxley

Source of image: timcoffeyart.wordpress.com

@helenbevan

‘I do not think you can really deal with change without a person asking real

questions about who they are and how they belong in the world’

David Whyte, The Heart Aroused 1994

Source of image: fistfuloftalent.com

@helenbevan

History tells us that personal transformation comes before

organisational or system transformation

If we want to play our role, we have to focus deeply on our own perspective and the ways

http://blogs.bmj.com/quality/2013/08/19/a-call-to-action-helen-bevans-blog-2/

we interact with and influence others. The more that we can unleash that powerful reservoir of energy for change, the more our influence and impact will grow.

Image from novamagazine.com

http://blogs.bmj.com/quality/2013/08/19/a-call-to-action-helen-bevans-blog-2/

@helenbevan

1. able to join forces with others to create action

2. able to achieve small wins which create a sense of hope, possibility and confidence

3. More likely to view obstacles as challenges to overcome

4. strong sense of “self-efficacy” belief that I am personally able to create the change

Four things we know about successful

boat rockers


CHANGE

me

BEGINS WITH

@helenbevan

Self-efficacy

There is a positive, significant relationship between the self-efficacy beliefs of a change agent and her/his ability to facilitate change

and get good outcomes

Source of image:www.h3daily.com

@helenbevan

What’s the difference between

self efficacyand

self esteem,self belief,

self-confidence?

@helenbevan


@helenbevan


What is the issue here?

“permission” ? (externally generated)

or

Self efficacy ? (internally generated)

@HelenBevan

Building self-efficacy: some tactics

1. Create change one small step at a time

2. Reframe your thinking:

• failed attempts are learning opportunities

• uncertainty becomes curiousity

3. Make change routine rather than an exceptional

activity

4. Get social support

5. Learn from the best

@helenbevan

The most effective change agents:

• don’t waste their time and energy blaming and complaining

• take calculated risks to achieve the outcomes they sought

Now is the time to plan steps to keep moving myself forward, with positive momentum, as a health and care radical

@helenbevan

Being a great change agent is about knowing, doing,

living and being improvement

@helenbevan

Avedis Donabedian

“Ultimately, the secret of quality is love.

…… If you have love, you can then work backward to monitor and improve the system”.

@helenbevan

Tactic for radicals:Out-love everyone else

Source of image: Bradley Burgess

@helenbevan

Questions for reflection

1. What are the opportunities for me to build my perspectives and skills as an agent of change?

2. How can I build self efficacy as a change agent?

3. How do I move beyond skills and knowledge of change to live and be change?

4. Who can help and support me as a change agent?

5. What are the implications for the way I work?

@helenbevan

What is a

RCT?

@helenbevan

Randomized Coffee Trial!

@helenbevan

Outcomes of randomised coffee trials

@helenbevan

Randomized Coffee Trial!• Instructions in News from Jo later today• Send an email to say you want to take part in the RCT to

[email protected]• We will randomly match you with another participant in the

School for Health and Care Radicals from anywhere in the world• At some time in the next four weeks, arrange to have a

conversation over Skype (or other communication system) with a cup of coffee!

mailto:[email protected]

@helenbevan

Learning from the first section

YOU can make a differenceAND

You can’t do it ALONE

Source: TED talk by Barry Posner http://workplacepsychology.net/2014/02/01/the-truth-about-leadership-you-make-a-difference-and-you-cant-do-it-alone/

Source of image: jamessamy.com

http://workplacepsychology.net/2014/02/01/the-truth-about-leadership-you-make-a-difference-and-you-cant-do-it-alone/

@helenbevan

Often as radicals, we feel different to other people

@helenbevanSource of image: outskirtsbattledome.wikispaces.com

The easiest way to thrive as an outlier

...is to avoid being one

Seth Goodin

@helenbevan



From module one

@helenbevan

What is community?1. Locality

2. Interest or shared purpose

3. Sense of belonging: “community spirit”

“There is no power for change greater than a community discovering what it cares about.”~ Margaret Wheatley

Source of image: rootedincommunity.org

@helenbevan

Power in community“Power used to come largely through and from big institutions.

Today power can and does come from connected individuals in community.

When community invests in an idea, it co-owns its success.

Source of image: orton.org

Instead of trying to achieve scale all by ourselves, we have a new way to have scale. Scale can be in, with and through community.”

Nilofer Merchant

@helenbevan

Who are your communities?

Source: Celine Schillinger http://weneedsocial.com/blog/2013/8/25/disrupted-disruptors-unite

• In your role: through relationships and social networks

• Through external social networks such as Twitter and LinkedIn

• Through communities of practice and learning groups

http://weneedsocial.com/blog/2013/8/25/disrupted-disruptors-unite

@helenbevan

“When we talk of social change, we talk of movements, a word that suggest vast

groups of people walking together, leaving behind one way and travelling towards

another”

Rebecca Solnit

@helenbevan

Learning from social movement leaders

http://www.slideshare.net/NHSIQ/the-power-of-one-the-power-of-many?qid=97bb3464-07c2-4883-9531-c3d436a66aa1&v=qf1&b=&from_search=2

http://www.slideshare.net/NHSIQ/the-power-of-one-the-power-of-many?qid=97bb3464-07c2-4883-9531-c3d436a66aa1&v=qf1&b=&from_search=2

@helenbevan

@helenbevan

Six characteristics of people or groups within effective social movements

1. They share a sense of PURPOSE: There is purposefulness about

collaborations, discussions, actions, decisions and a sense of forward momentum

2. They are UNITED: They have learned to manage their differences well enough

that they can unite to accomplish their purpose. Differences are openly debated, discussed, and resolved.

3. They share UNDERSTANDING: There is a widely shared understanding of what's going on, what the challenges are and why what is being done has to be done

4. People PARTICIPATE: Lots of people and organisations in the system are

active - not just in discussions and meetings, but getting the work done.

5. They take INITIATIVE: Rather than reacting to whatever happens in their

environment, they are proactive, and act upon their environment.

6. They ACT: People do the work they must do to

make the things happen that need to happen

Source: adapted from Wellstone Action

@helenbevan

Calls to Action

@helenbevan

Leadership is….

…the art of mobilising others to want to struggle for shared

aspirationsJim Kouzes

Source of image: environmentvictoria.org.au

@helenbevan

What is strategy?

Strategy is the process of turning the you have into the you need to win

the you wantSource: Marshall Ganz

@helenbevan

Resources to improve health and care

Economic resourcesdiminish with use• money• materials• technology

Natural resourcesgrow with use• relationships• commitment• community

Based on principles from Albert Hirschman, Against Parsimony

@helenbevan

Framing… is the process by which leaders construct, articulate and put across their message in a powerful and compelling way in order to win people to their cause and call them to action.

Snow D A and Benford R D (1992)

@helenbevan

What’s the financial incentive?

Who is performance managing?

What’s theproject plan?

Source: @RobertVarnam

@helenbevan

The reality“What the leader cares about (and typically bases at

least 80% of his or her message to others on) does not tap into roughly 80% of the workforce’s primary motivators for putting extra energy into the change

programme”Scott Keller and Carolyn Aiken (2009)

The Inconvenient Truth about Change Management

Source of image: swedenbourg-openlearning.org.uk

@helenbevan #IQTGOLD#NHSChangeDay

“I have some Key

Performance

Indicators

for you”

or

“I have a

dream”

Source: @RobertVarnam

@helenbevan

Leaders ask their staff to be ready for change, but do not engage enough in sensemaking........

Sensemaking is not done via marketing...or slogans but by emotional connection with employees

Ron Weil

@helenbevan#NHSChangeDay #SHCRchat

If we want people to take action, we have to connect with their emotions through values

action

values

emotion

Source: Marshall Ganz

@helenbevan


But not all emotions are equal.........

inertiaurgency

anger apathy

solidarity isolation

you can make a difference

Self-doubt

hope fear

Overc

om

es

Action motivators Action inhibitors



‘‘Leaders must wake people out of inertia. They must get people excited about something they’ve never seen before, something that does not yet

exist”

Rosa Beth Moss Kanter

Source of image: www.linkedin.com/company/activate-brand-agency

http://www.linkedin.com/company/activate-brand-agency

@helenbevan

Effective framing: what do we need to do?

1. Tell a story

Source of image: woccdoc.org

@helenbevan

http://www.slideshare.net/amitkaps/fifth-elephant-2014-talk-crafting-visual-stories-with-data?sf3881865=1

http://www.slideshare.net/amitkaps/fifth-elephant-2014-talk-crafting-visual-stories-with-data?sf3881865=1

@helenbevan


1. Tell a story

2. Make it personal


@helenbevan


1. Tell a story

2. Make it personal

3. Be authentic


@helenbevan


1. Tell a story

2. Make it personal

3. Be authentic

4. Create a sense of “us” (and be clear who the “us” is)


@helenbevan


1. Tell a story

2. Make it personal

3. Be authentic

4. Create a sense of “us” (and be clear who the “us” is)

5. Build in a call for urgent action



Vivid details



How do we create a sense of “us” to build momentum for

change?

Source of image: www.tannerfriedman.com

http://www.tannerfriedman.com/

@helenbevan

Moving beyond us and them to us and us

Source of image: www.delta7.com

http://www.delta7.com/

@helenbevan

The Network Secrets of Great Change AgentsJulie Battilana &Tiziana Casciaro

1. As a change agent, my centrality in the informal network is more important than my position in the formal hierarchy

2. If you want to create small scale change, work through a cohesive network

If you want to create big change, create

bridge networks between disconnected groups

From Module 1

@helenbevan

strong ties (cohesive)v.

weak ties (disconnected)

Source of image: http://www.forbes.com/fdc/welcome_mjx.shtml

http://www.forbes.com/fdc/welcome_mjx.shtml


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, social worker to social worker, nurse to nurse, community leader to community leader

• Influence is spread through people who are strongly connected to each other, like and trust each other


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, social worker to social worker, nurse to nurse, community leader to community leader

• 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


The pros and cons of strong ties

Pros Cons

@helenbevan

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

• We can mobilise all the resources in our organisation, system or community to help achieve our goals

@helenbevan

Why we need to build weak ties AS WELL AS strong ties

• Weak ties are more likely to lead to change at scale because they enable us to access more people with fewer barriers

More on weak ties: https://www.youtube.com/watch?v=w7AzRVxhEXA#t=45

https://www.youtube.com/watch?v=w7AzRVxhEXA#t=45

@helenbevan



• 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

@helenbevan



• 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

• The most breakthrough innovations and most radical change will come when we tap into our weak ties

@helenbevan

Sources of weak ties

@helenbevan

Three components of a great narrative

• Diagnostic – what is the problem that we are addressing? What is the extent of the problem? What is the specific source or sources?

• Prognostic – what could the future look like? What is our “plan of attack” and our strategy for carrying out the plan?

• Motivational – why is this urgent? What is our call for action that connects with the motivational and emotional drivers of our audience?

Source: Benford and SnowSource of image: www.ecommercedefense.com

http://www.ecommercedefense.com/

@helenbevan

Four keys to collaboration

• Lean into your discomfort

• Listen as an ally

• State your intent

• Share your “street corner”Source: Judith Katz and Fred Miller

@helenbevan

@helenbevan

Four keys to collaboration

• Lean into your discomfort

• Listen as an ally

• State your intent

• Share your “street corner”Source: Judith Katz and Fred Miller

@helenbevan 115

http://weneedsocial.com/blog/2013/8/25/disrupted-disruptors-unite

@helenbevan

Source of image: http://switchandshift.com/transactional-or-transformational-which-leadership-style-is-best

http://switchandshift.com/transactional-or-transformational-which-leadership-style-is-best


“You don’t need an engine when you have

wind in your sails”

@helenbevan


1. What learning and inspiration can you take from social movement leaders to help you in your role as an agent of change in health and care?

2. How will you attract the attention of the people you want to call to action?

3. Who are the people who are currently disconnected that you want to unite in order to achieve your goal for change? How can you build a sense of “us” with them?

@helenbevan

Employee resistance is the most common reason executives cite for the

failure of big organizational-change

effortsScott Keller and Colin Price

(2011), Beyond Performance: How Great Organizations Build Ultimate

Competitive AdvantageSource of image: Businessconjunctions.com

@helenbevan

“Thousands of patients have died

needlessly because of a damaging reluctance amongst

doctors and the public to accept changes in the NHS, according to

the country’s top emergency doctor

“


What do we mean by

?

@helenbevan Source of image: sport-fitness-advisor.com

Any force that stops or slows movement

Resistance

@helenbevan

In module 1, we talked about:

@helenbevan

Let’s think about this in the context of “resistance”


Leading change in a new eraDominant approach Emerging direction

• Change can be planned and managed through a rigorous process

• Resistance is a force to overcome

• Resistance prevents change

• Change agents mustdiagnose, manage and/or overcome resistance

• Resisters can otherwise be known as “laggards”, “blockers”, “in denial”

@helenbevan

Resistance to change: the dominant approach

@helenbevan

An example “dominant approach” transformation programme

@helenbevan

“The role of the change agent is to recognise the causes of resistance and address each one. If this is not done, then the change will be much harder to

implement successfully and may not succeed at all”

David StonehouseThe change agent: the manager’s role in change

British Journal of Healthcare Management, Vol. 19, Iss. 9, 09 Sep 2013, pp 443 - 445

Dominant approach: the role of the change agent

http://www.bjhcm.co.uk/cgi-bin/go.pl/library/contents.html?uid=4973;journal_uid=22



• Change in human systems is often emergent and hard to predict

• Change results from connections/interactions stimulating different perspectives, shaping how people think about things

• Resistance is an inevitable consequence of a complex change process

• Resistance should be embracedand rolled with


• Change can be planned and managed through a rigorous process

• Resistance is a force to overcome

• Resistance prevents change

• Change agents mustdiagnose, manage and/or overcome resistance

• Resisters can otherwise be known as “laggards”, “blockers”, “in denial”


“Change doesn’t rain down on us from on high. Rather, its stories are co-

created and co-owned by the community. Or, at least they are if you want

the change to stick”Julian Stodd

https://julianstodd.wordpress.com/2013/11/29/the-co-creation-and-co-ownership-of-organisational-change/

https://julianstodd.wordpress.com/2013/11/29/the-co-creation-and-co-ownership-of-organisational-change/

@helenbevan

Leaders ask their staff to be ready for change, but do not engage enough in sensemaking........

Sensemaking is not done via marketing...or slogans but by emotional connection with employees

Ron Weil

@helenbevan

Resistant behaviour is a good indicator of missing relevance

Harald Schirmerhttp://de.slideshare.net/haraldschirmer/strategies-for-corporate-change-the-new-role-of-hr-driving-social-adoption-and-change-in-the-enterprise

Source of image: driverlayer.com

‘‘

http://de.slideshare.net/haraldschirmer/strategies-for-corporate-change-the-new-role-of-hr-driving-social-adoption-and-change-in-the-enterprise

@helenbevan

Cultural change is a million

subversive acts of resistance

Brene Brown

Source of image: zazzle.com

‘‘


Language constructs our world(s) rather than reports the objective facts about the world. Therefore changing when, where, how and which people

talk about things – changing the conversation – will lead to

organisational changeRobert J Marshak

Source of image: createbusiness.net.au

‘‘

@helenbevan

1. Create the conditions for transformational conversations by asking questions that are focussed on future possibilities, by inviting diversity into the system and by being welcoming

2. Create opportunities for everyone to express their views, spot opportunities and build on each other’s ideas

3. Create ways for people to reflect together to find meaning, understanding and shared purpose in the change

Source: Peggy Holman

Emerging direction: the role of the change agent

Source of image: rachtalks.pressprestige.com

@helenbevan

“Having care wrapped around the person rather than the person pushed through the system”

Lesley Young-MurphyNorth Tyneside Clinical Care Group

@helenbevan

“The most basic not-so-secret formula for building an innovation culture is pretty simple - embrace diversity and start to attract, retain and promote a diverse workforce that looks differently, works differently, dress differently, speaks differently and is inclusive of the full spectrum of human sexual orientation and gender identities. Do this before you start hiring consultants and rethinking your innovation process, there is no process that works without true diversity.”

Idris Moore

Source of image: idsgn.org

Diversity is critical to innovation and change

@helenbevan

“Leaders and organisations must let go of the idea that there is “one right way” and instead focus on creating a learning culture where people feel accepted, are comfortable contributing ideas, and actively seek to learn from each other”

Diaz_Uda, Medina and Schill (2013)

Source of image:fineartamerica.com

As health and care radicals, we should be champions of diversity for change

@helenbevan

In the context of “rolling with resistance”

• What are the implications of embracing diversity of thought, experience and background in our change efforts?

• What skills and perspectives do health and care radicals need to work effectively with diverse teams for change?

Source of image:fineartamerica.com

Discussion

@helenbevan

Our effectiveness as change agents is not a matter of intention; it’s a matter of impact

@helenbevan

• Helen’s intent was to give people quick solutions, help them do their work faster and get on to the next problem at hand

• However, her impact was that people did not know how to solve their own problems so that Helen’s style was impeding their development

Source: adapted from Intent vs. Impact: A Leadership Lesson by Claudia Busch Lee

Source of image: thedigitalawards.com

@helenbevan

Stop talkingAT ME

Start talkingTO ME

Source of image: prepbeijing.com

@helenbevan

• Build a trusting and supportive work environment

• Listen like an ally • Be open with my intent

• Fully commit to the change• Seek common purpose and common

interests• Take time to build relationships• Take responsibility for my own actions

What can I do?

@helenbevan

@helenbevan

If your horse dies, get off it

Cherokee proverb

Source of image: fenwickgallery.co.uk

‘‘

@helenbevan#SHCR @School4RadicalsImage copyright: http://13c4.wordpress.com/2007/02/24/50-reasons-not-to-change/

@helenbevan

C http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively

http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively

@helenbevan Source: http://www.slideshare.net/AndreaWaltz/gfn-slidesharegfnhandling-rejectionpositively



Make it a personal PERFORMANCE target.


@helenbevan

Research from the sales industry:How many NOs should we be seeking to get?

• 2% of sales are made on the first contact

• 3% of sales are made on the second contact

• 5% of sales are made on the third contact

• 10% of sales are made on the fourth contact

• 80% of sales are made on the fifth to twelfthcontact

Source: http://www.slideshare.net/bryandaly/go-for-no

http://www.slideshare.net/bryandaly/go-for-no

@helenbevan

“Papers that are more likely to contend against the status quo are more likely to find an

opponent in the review system—and thus be rejected —but those papers are also more

likely to have an impact on people across the system, earning them more citations when

finally published”

V. Calcagno et al., “Flows of research manuscripts among scientific journals reveal hidden submission patterns,”

Science, doi:10.1126/science.1227833, 2012.

—

@helenbevan

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“Stages of change” Transtheoretical model of behaviour change

Prochaska, DiClemente & Norcross (1992)

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• smoking cessation

• exercise adoption

• alcohol and drug use

• weight control

• fruit and vegetable intake

• domestic violence

• HIV prevention

• use of sunscreens to prevent skin cancer

• medication compliance

• mammography screening

The model is mostly used around health-related behaviours

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• smoking cessation

• exercise adoption

• alcohol and drug use

• weight control

• fruit and vegetable intake

• domestic violence

• HIV prevention

• use of sunscreens to prevent skin cancer

• medication compliance

• mammography screening

It works for organisational and service change too!

The model is mostly used around health-related behaviours

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“Stages of change” Smoking

I am not aware my smoking is a

problem – I have no intention to quit


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I know my smoking is a problem – I

want to stop but no plans yet


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I am making plans & changing things

I do in preparation.



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I have stopped smoking!



@helenbevan







I have stopped smoking!

I am continuing to not smoke.

I sometimes miss it – but I am still not

smoking



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“Stages of change” Transtheoretical model of behaviour change

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• Which stage do most change activities in health and care focus on?

• Which stage are most people actually at?

Some questions

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The reality of our change situation

• Our tools are often not effective at the stage of change that most people we work with are at

• It’s hard to engage people in change

• It’s hard to get people to make the changes we want them to make

• People get irritated, defensive, irrational

• We feel powerless in our ability to lead or facilitate the change

90% of the tools available for health and care change agents are designed for the “action” stage


• Designed for Stage 4 –ACTION!

• Mandated it through targets

• Despite compelling case for change –people resisted it – no values connection

• People did the task and missed the point

Example – WHO Surgical Safety Checklist

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IN A NUTSHELL

• Evidence from observational studies that the use of surgical safety checklists results in striking improvements in outcomes

• Led to rapid adoption of such checklists worldwide

• Researchers studied effect of mandatory adoption of checklists in Ontario, Canada

• Use of checklists not associated with significant reductions in operative mortality or complications

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• Lower our ambitions for improvement• Focus our energies on those who are

already in the “action” stage• Put negative labels on those who are

not yet at the action stage such as “blocker” or “resister” or “laggard”

• Blame “the management” for not enforcing change

So what do we TEND to do when people resist?

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The single biggest problem in communication is the illusion that it has taken

place

George Bernard Shaw

‘‘

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• Listen and understand• appreciate the starting point

• elaborate interests

• Roll with resistance (Singh)

• Don’t argue against it• Encourage elaboration of resistance

• What makes it so hard?• What would help?

• Build meaning and conviction in the change

So what SHOULD we do?

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• The focus should be on creating awareness for me of the need to change

• Remember the goal is not to make me (as a precontemplator) change immediately, but to help me move to contemplation

• I am not thinking about changing my behaviours, actions or work processes

• The problem or issue is outside my frame of awareness or my perceived need

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Focussing on Prochaska, DiClemente and Norcross’s Stages of Change model:

• What stage of change are some of the key people that you need to influence for your change initiative at?

• What actions can you take to help them move to the next stage?

Thinking about your own situation

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“Tomorrow’s management systems

will need to value diversity, dissent and

divergence as highly as conformance, consensus

and cohesion.”

Gary Hamel

Source of image: www.fastcompany.com

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1. What does resistance means to you?

think about the things you resist as well as your responses to others’ resistance

2. How do you work with resistance as a change leader?

3. How can you make sure that the changes you make achieve the impact you desire and also

are sustainable?

do not create dependency?

generate self-efficacy in others?

4. Who you are interacting with and where they are on the Stages of Change model?


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The “two levels down” rule

What can I achieve in:

a year?

a month?

a week?

a day?

an hour?

If you think your improvement initiative will take a year to test and implement, consider what you could achieve in a week

If you think it will take a week, what you could achieve in an hour?

Source: Paul Plsek

school of health care radicals

Healthcare

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networkmany change agents

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