translating large-scale change into everyday improvement
DESCRIPTION
This presentation was delivered in sessions E7 and F7 of Quality Forum 2014 by: Marlies van Dijk Director, Clinical Improvement BCPSQC Geoff Schierbeck Quality Leader, Surgery BCPSQC Meher Shergill Quality Leader BCPSQCTRANSCRIPT
LEADING LARGE SCALE CHANGE
Marlies van Dijk, Geoff Schierbeck & Meher Shergill Quality Forum 2014
At present, prevailing strategies [in healthcare] rely largely on outmoded theories of control and standardisation of work. More
modern and much more effective, theories seek to harness the imagination and
participation of the workforce in reinventing the system
Don Berwick, Former CEO, Institute for Healthcare Improvement
What will you walk away with?
• Fundamental elements that define large scale change
• Overall framework for large scale change
• Key practical tools and strategies to support you in your change efforts.
• Hopefully get you to try some of these when you get back home!
© NHS Institute for Innovation and Improvement, 2012
A working definition Large Scale Change
Large-scale change is the emergent process of moving a large collection of individuals, groups and
organisations to a fundamentally new future state.
Large Scale Change – What is it and What is it not?
Incremental Change – Process improvement – Relatively constant shape of a flowing river
Large-Scale Change
– Transformational, qualitatively different changes – Damming a river or altering its course
Source: P. Plsek. Creating Large Scale Change in Health Care. 2011
Multiple of things (lots of lots)
© NHS Institute for Innovation and Improvement, 2012
Summarising the key differences in the approach to large scale change and “normal” change
Normal Change Large Scale Change
Credible ambition
defined future state
clear organisation scope
agreed leaders throughout
processes or systems or behaviours
strong programme management
controlled through hierarchy
compliance led*
Incredible ambition
managing an emergent final state
multiple organisations and partnerships
distributed and changing leadership
processes and systems and behaviours
programme management and social movement
managed through influencing and engagement
commitment led
Differences
*Compliance can lead to commitment for some
© NHS Institute for Innovation and Improvement, 2012
Similarities
Normal Change and LSC
Working to an inspiring vision
Use best practice improvement tools
Require great leadership
Require effective team working
Urgency for delivery
Summarising the key similarities in the approach large scale change and “normal” change
What are some good examples of Large Scale Change?
What makes it large scale?
Your turn
Three Core Elements
1.Structure 2.Process 3.Patterns of Behaviour
Structures only (no process or behaviour)
Process only (no structure or behaviour)
Behaviour only (no structure or process)
What happens when …
Trajectories of Improvement
Time
Project Approach to improvement -
Common
Structures/ Processesand
Behavior Desired
© Charles Kilo, MD,GreenField Health
Impr
ovem
ent
Ideal
Approach to improvement - None
© NHS Institute for Innovation and Improvement, 2012
Model of Large Scale Change
Large Scale Change Tools
• Planning questions • Driver diagrams • 30/60/90 day cycles of change • Systems and stakeholders
analysis • Continuum of commitment
analysis • Framing and reframing • Mindsets • Transformational story telling • World Café • Measurement
Thinking
• Structure, process and pattern thinking
• Culture • Complex Adaptive System
Elements • Network Theory
Driver Diagrams
• Useful for group of leaders overseeing the LSC effort • Take a high level improvement goal
— determine underpinning goals (“drivers”) — determine projects/change ideas that will help you to
achieve • Visual of entire change process
– Inter-connections – Communication tool
• Framework for measurement • Update every 90 days
The “Steps”
Source: NHS Institute for Innovation & Improvement
What Changes Can We Make?
Primary Drivers System components which will contribute to
moving the primary outcome Secondary Drivers
Elements of the associated primary driver. They can be used to create projects or a change package that will affect the primary drivers.
Improve the Quality of
Surgical Care in BC
Skill Building
Face to Face Sessions
Site Visits
Distributed Leadership
Data
Multidisciplinary Partnerships
Patient Perspective
Clinical Leadership
Culture Survey
Teamwork + Communication
OR Team Training
Site level/ Regional events or Visits
Frontline Providers
Clinicians, Nurses, Administrators, BCMA, BCAS,
CRNBC
Local Risk Adjusted Model
Support how to share data
Patient Voice (video)
Physician Meeting
Quality Improvement
Cohesive Group – Tie in Efficiency Ministry + Board
Influence/support
Collaborative Sharing and Learning
Use clinical leaders to engage others
Patients on Planning Group
Looking Fashiona
ble
Fashion magazines
Stretch
With friends
HOW
Aim / Outcome(s)
Primary Drivers
Secondary Drivers / Change Concepts
Specific Ideas to Test
Winners
HOW HOW
WHY WHY WHY
Source: L. Couves, Improvement A i
Buying good shoes Check out
competition
Driver Diagram
• Key themes that will make a difference • Mutually reinforcing changes in multiple areas • Where does commitment contribute
Aim: Quit smoking or other Primary Driver: Secondary Driver: Specific Ideas:
Framing
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 workforces’ primary motivators for putting extra energy into the change programme. The inconvenient truth about change management, McKinsey Quarterly
Turning an opportunity into action … −Picture frames – what is in it you see, what is outside
you do not −Provide shape and structure for organising ideas and
arguments − ‘Hooks’ for pulling people in − ‘Springboards’ for mobilising support −Need to be authentic and connect with an
individual’s reality
Our aspiration is to have a healthcare system with: • no needless death or disease • no needless pain • no unwanted delay • no feelings of helplessness (for patients or staff) • no waste • and no inequality in service delivery
Adapted from: Don Berwick by Pursuing Perfection)
How do we create change at scale?
Source: Marshall Ganz and Helen Bevan
Shared understanding leads to Action
Narrative
why?
Strategy
what?
Building advanced improvement capability for BC
Building advanced improvement capability for BC
Clinical and Mobilisation Clinical Mindsets for Improvement Effectiveness and Efficiency Metrics and Measurement Clinical Systems Improvement Reducing Variation Pathway Redesign Evidence Based Practice
The Mobilisation Mindsets for Improvement Energy for Change Imagination Engagement Moving Mobilising Calling to Action Creating the Future
Mindset Shift From …. “current mindset” ‒ Hierarchy – I don’t question those
above me ‒ Professional silos ‒ Complications (e.g., infections) are
part of our business ‒ Partners must comply with what
we tell them to do
To … “future mindset” ‒ No infection is acceptable ‒ I can speak up when I have
concerns ‒ Patients are equal partners ‒ We work in teams
Your Turn: Goal (area of work)
From …. “current mindset”
To … “future mindset”
Why is change so hard in health care?
• Pilot projects generally do well
• Spreading throughout our system has proven to be difficulty
• Often attributed to variation at a local level
Complex Adaptive Systems
Complex adaptive systems are composed of many interdependent, heterogeneous parts that self organize and co-evolve.
Unpredictable
(Camazine, 2001; Kauffman, 1995; Allen & Varga, 2006)
Self-Organization
Self-organization is a process whereby local interactions give rise to patterns of organizing.
ADAPTIVE – RESILIENT – UNCERTAIN
(and difficult to manage)
H.J. Lanham et al., How complexity science can inform scale-up and spread in health care: Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)
Interdependencies Overarching term for relationships, connections, and interactions among parts of a complex system.
Pre-Intervention Post-Intervention
Lindberg, C., & Clancy, T. R. (2010). Journal of Nursing Administration
Sense Making
So now what? How do we lead in a complex system…
Acknowledge Unpredictability • Allow design to be tailored to local contexts • Emphasize discovery in each intervention setting Recognize Self-Organization • Develop “good enough” • Facilitate sense-making
H.J. Lanham et al., How complexity science can inform scale-up and spread in health care: Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)
So now what? How do we lead in a complex system…
Facilitate Interdependencies • Reinforce existing relationships when effective or foster new
ones • Encourage sense-making Encourage Experimentation • Encourage participants to ask questions, admit ignorance and
deal with paradox • Seek out different points of view
H.J. Lanham et al., How complexity science can inform scale-up and spread in health care: Understanding the role of self-organization in variation across local contexts. Social Science & Medicine (2012)
Strong ties vs weak ties (social network theory)
When we spread change through strong ties … – Interact with “people like us” with the same experiences,
beliefs and values – Change is peer to peer (e.g., nurse to nurse, GP to GP) – Influence is spread through people who are strongly
connected to each others, who like and generally respect each other
– It works because people are far more likely to be influenced to adopt new behaviors or ways of working from those they are most strongly tied
Source: Helen Bevan, 2011
Power of Networks
Strong Ties – Group Exercise
Advantages of Strong Ties
Disadvantages of Strong Ties
What About “Weak Ties”?
When we seek to spread change through weak ties: – We build bridges between groups and individuals
who are 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 mobilize all the resources in our system
Weak Ties– Group Exercise
Advantages of Weak Ties
Disadvantages of Weak Ties
We need BOTH strong and weak ties …
• Weak ties enable change at scale because they enable us to access more people with fewer barriers
• In situations with uncertainty, we gravitate to our strong tie relationships
– evidence shows that weak ties are much more important than strong ties
• More breakthroughs in innovation occur when we tap into weak ties
• The greatest opportunity we likely have for large scale improvement and change is through weak ties
• When framing your story – consider BOTH strong and weak ties
Source: Helen Bevan, 2011
From Compliance
States a minimum performance standard that everyone must achieve
Uses hierarchy, systems and standard procedures for co-ordination and control
Threat of penalties/sanctions/shame creates momentum for delivery
Based on organisational accountability (“if I don't deliver this, I fail to meet my performance objectives”)
To Commitment
States a collective improvement goal that everyone can aspire to
Based on shared goals, values and sense of purpose for co-ordination and control
Commitment to a common purpose creates energy for delivery
Based on relational commitment (“If I don’t deliver this, I let the group or community and its purpose down”)
The new era requires a shift in thinking
Source: Helen Bevan
Building Commitment and Connection
Key Players No Commitment
Let It Happen Help It Happen Make It Happen
Unit Clerks X O
Administration X O
QI X O
etc XO
etc X O
etc XO
Three Strategies: 1. Mobilizing narratives 2. Authentic Voices (e.g., Patients for Patient Safety Canada) 3. Hot-housing (e.g., energizing meetings and events out of usual
environment)
The Value of Commitments
• We commit to specific actions that are measurable – not vague promises – not just outcomes
• Make commitments as simple as possible (“one specific action”)
• We want to hold people to account to the things that they commit to
• When we do it effectively, commitment is much more effective than compliance
• A definite “no” is always better than a wishy-washy “yes” or “maybe”
Source: NHS Institute for Innovation and Improvement, 2011
If we apply mindsets, values and social movement principles … Here is an example!
• Identifying need for change • Framing/Reframing the issue • Engaging the community • Attracting further interest
• Mindset shift: “from compliance to commitment”
• Driver Diagram • Stakeholder analysis • Network theory • Social Movement theory • Strategy. Narrative. Action
• Communicate frequently, carefully • Positive affirmation works • Local champions and regional connections
are key • Collective responsibility & willing
commitment can be an ally • Frequent feedback of results is effective in
stirring change • Gamification can be effect to spread best
practice
150 Lives – Lesson Learned
Application
• What are you currently working on that could use one of the large scale methods?
Driver Diagram Framing Mindset Exercise Weak ties/Strong ties
Questions?
Marlies van Dijk [email protected]
@tweetvandijk
Geoff Schierbeck [email protected]
@bcsurgquality
Meher Shergill [email protected]