and staying in it:
How to be a great change agent
www.changeday.nhs.uk/healthcareradicals
Helen Bevan
@HelenBevan
Source of image: showstudio.com
Leadership Assessment 10 credits
• Reflective diary/ journal
• Use a case study
• the interpersonal challenges and
achievements of leading others in relation to
your quality improvement work based project.
@HelenBevan
Learning outcomes being assessed
• Critical understanding of key theories, concepts, models and techniques
underlying a range of strategies for leading others, with reference to own
organisational context.
• Critical understanding of political, ethical, legal and other challenges facing
professionals as effective improvement practitioners.
• Independently seek out knowledge relevant to developing strategies for
improvement in own organisation.
•
Constructively question and analyse professional practices related to own
organisational context.
• Exercise own initiative in identifying problems and developing innovative
and viable solutions.
• Structure and communicate ideas effectively to both academic and
organisation-based audiences.
• Elicit, take account of, critically evaluate and respond to views of
stakeholders and colleagues in own workplace.
@HelenBevan
@HelenBevan
Source of image: Whatsthebigideascwartzy.blogspot.com
Most large scale change doesn’t fully
deliver its objectives
5%
Gets anywhere near
achieving the
change and
delivering the
benefits
25%
70%
Source: McKinsey Performance Transformation Survey, 3000 respondents to
global, multi-industry survey
@HelenBevan
Most large scale change doesn’t fully
deliver its objectives
5%
Delivers and
sustains the change
25%
70%
Source: McKinsey Performance Transformation Survey, 3000 respondents to
global, multi-industry survey
@HelenBevan
Most change efforts are built upon the shaky foundation of
five flawed assumptions; that change can be managed, that
human beings are objective, that there are ‘X’ steps to
change, that we have a neutral starting point for change, and
that change, itself, is the goal
Peter Fuda
http://www.peterfuda.com/wp-content/themes/peterfudabootstrap/content/Why-Change-Efforts-Fail.pdf
@HelenBevan
Source of image: Whatsthebigideascwartzy.blogspot.com
Front line teams get inundated with high priority
messages from leaders each day, making it
difficult for them to know what to focus on
Increasing number of messages
as information cascade through
the organisation
Source: adapted from
http://businessjournal.gallup.com/content/162707/change-initiatives-faildon.aspx
@HelenBevan
Front line teams get inundated with high priority
messages from leaders each day, making it difficult for
them to know what to focus on
Increasing number of messages
as information cascade through
the organisation
Buy in from front line staff is critical for
improvements in quality and safety . Don’t
overload them
Buy in from front line staff is critical
for improvements in quality and safety
Source: adapted from
Don’t overload them
http://businessjournal.gallup.com/content/162707/change-initiatives-failhttp://healthaffairs.org/blog/2014/03/07/thedon.aspx
dangers-of-quality-improvement-overload-insightsfrom-the-field/
@HelenBevan
Leading change in a new era
Dominant approach
@HelenBevan
Emerging direction
@HelenBevan
@HelenBevan
John Kotter: “Accelerate!”
• We won’t create big change through hierarchy
on its own
• We need hierarchy AND network
• Many change agents, many acts of leadership
• At least 50% buy-in
Source of
image:www.slideshare.net/m
exicanwave/champions-trolls• Changing our mindset
10-years-of-the-cipd-online• From “have to” to “want to”
@HelenBevan
community
The Network Secrets of Great Change Agents
Julie 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
@HelenBevan
Image copyright: http://13c4.wordpress.com/2007/02/24/50-reasons-not-to-change/
@HelenBevan
What happens to
heretics/radicals/rebels/mavericks
in organisations?
@HelenBevan
@HelenBevan
Valuing radicals
• “New truths begin as heresies” (Huxley, defending
Darwin’s theory of natural selection)
• Big things only happen in organisations and systems
because of heretics and radicals
GALILEO DESCRIBES HIS DISCOVERIES TO THE CHURCH ESTABLISHMENT
@helenbevan
@HelenBevan
The 90/30 conundrum
of senior leaders say
that to create more
innovation, they need to
activate the
radicals/rebels in their
organisations or systems
@helenbevan
@HelenBevan
of senior leaders are
very satisfied that
radicals/rebels can
provide this value in
their organisations or
systems
Source: rebelsatwork.com
We need to be boatrockers!
• Rock the boat but manage to
stay in it
• Walk the fine line between
difference and fit, inside and
outside
• 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
Source: Debra Meyerson
destructive troublemaker
@helenbevan
@HelenBevan
There’s a big difference between a rebel
and a troublemaker
Rebel
@helenbevan
Source : Lois Kelly www.rebelsatwork.com
Peter Fuda’s Transformational Change Agent
framework
Skills and methods for creating
change
Ability to make sense of, and reshape
perceptions of ‘reality’
Personal characteristics and
qualities
@helenbevan
@HelenBevan
Peter Fuda’s Transformational Change Agent
framework: my perspective
“Doing”
• Where most change agents
in health and care put most
of their effort and emphasis
• What others typically judge
us on
• What we often perceive we
need to do to add value
• What most change and
improvement courses focus
on
@helenbevan
@HelenBevan
Peter Fuda’s Transformational Change Agent
framework: my perspective
“Seeing ” and “Being”
• We can only do effective
“doing” if we build on strong
foundations of “seeing and
being”
• Change begins with me
• Hopeful futures, creative
opportunities and potential
• Multiple lenses for change
• See myself in the context of
my higher purpose
@helenbevan
@HelenBevan
“Being” as a change agent
Personal characteristics and
qualities
@helenbevan
@HelenBevan
"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
@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
@helenbevan
@HelenBevan
Source of image: fistfuloftalent.com
Five things we know about successful
boat rockers
CHANGE
BEGINS WITH
1. Driven by conviction and values
me
2. strong sense of “self-efficacy”
 belief that I am personally able to create the change
3. able to join forces with others to create action
4. able to achieve small wins which create a sense
of hope, self-efficacy and confidence
5. More likely to view obstacles as challenges to
overcome
@helenbevan
@HelenBevan
Source: adapted from Debra E Meyerson
Source: @NHSChangeDay
@helenbevan
@HelenBevan
Source: @NHSChangeDay
What is the issue here?
“permission” ?
(externally generated)
or
Self efficacy ?
@helenbevan
@HelenBevan
(internally generated)
Building self-efficacy: some tactics
1. Invest in your own change agent development
• create the conditions where success is more likely to happen
2. Create change one small step at a time
3. Reframe your thinking:
• failed attempts are learning opportunities
• uncertainty becomes curiousity
4. Make change (and learning cycles from change) routine
rather than an exceptional activity
5. Get social support
6. Learn from the best
7. Get people whose opinions you value to encourage you
(mentor?)
@helenbevan
@HelenBevan
“Being” as a change agent
• Living my conviction and values
• Strong sense of “self-efficacy”
 belief that I am personally able to create the
change
• Stepping outside my comfort zone
• A “rebel” rather than a “troublemaker”
• Learning not judging
CHANGE
BEGINS WITH
#NHSChangeDay #SHCRchat
@HelenBevan
me
“Seeing” as a change agent
Ability to make sense of,
and reshape perceptions of
‘reality’
@helenbevan
@HelenBevan
Seeing
“Seeing, looking, monitoring, listening,
perceiving and especially the indefinite concept
of intuitive feeling ”
Aubrey Jango
@helenbevan
@HelenBevan
Task
Have a table discussion:
What are some of the different ways of “seeing”
change?
@helenbevan
@HelenBevan
What do we mean by
resistance to change?
@helenbevan
@HelenBevan
Resistance
Any force that stops or
slows movement
Source of image: sport-fitness-advisor.com
@helenbevan
@HelenBevan
Employee resistance is the
most common reason
executives cite for the
failure of big
organizational-change
efforts
Source of image:
Businessconjunctions.com
@helenbevan
@HelenBevan
Scott Keller and Colin Price
(2011), Beyond Performance: How
Great Organizations Build Ultimate
Competitive Advantage
Diagnostic
and
dialogic
approaches
to
resistance to change
@helenbevan
@HelenBevan
Resistance: a “diagnostic” approach
• Change is something that happens “out there”
in the organisation or system
• Resistance is a force to overcome
• Resistance prevents change
• Change agents must diagnose, manage and/or
overcome resistance
• Resisters may be otherwise known as
“laggards”, “blockers”, “in denial”
@helenbevan
@HelenBevan
Resistance to change
@helenbevan
@HelenBevan
Diagnostic: the role of the change agent
“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 Stonehouse
The change agent: the manager’s role in change
British Journal of Healthcare Management, Vol. 19, Iss.
9, 09 Sep 2013, pp 443 - 445
@helenbevan
@HelenBevan
Resistance: a “dialogic” approach
• People make their own reality
• Change results from transformational
conversations
 involving more and different people in change discussions
 altering how and which people engage with each other
 by stimulating different perspectives to shape how people
think about things
• Resistance is an inevitable consequence of a
complex change process (based on diversity)
• Resistance should be embraced and worked with
@helenbevan
@HelenBevan
Dialogic: the role of the change agent
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
@helenbevan
@HelenBevan
Diversity is critical to innovation and change
“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
@helenbevan
@HelenBevan
Source of image: idsgn.org
Health and care radicals should be champions
of diversity for change
“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)
@helenbevan
@HelenBevan
Source of image:fineartamerica.com
Discussion
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?
@helenbevan
@HelenBevan
Source of image:fineartamerica.com
The effectiveness of change agents is not a
matter of intention; it’s a matter of impact
@helenbevan
@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
@HelenBevan
Stop talking
AT ME
Start talking
TO ME
Source of image: prepbeijing.com
@helenbevan
@HelenBevan
What should I do to manage intent and
impact?
• Build a trusting and supportive work
environment
• Listen with an open heart and open mind
• Commit to the change 100%
• Seek common purpose and common
interests
• Take time to build relationships
• Be open with my intent
• Take responsibility for my own actions
@helenbevan
@HelenBevan
@helenbevan
@HelenBevan
If your horse dies,
get off it
Cherokee proverb
@helenbevan
@HelenBevan
Source of image: fenwickgallery.co.uk
Task
Have a discussion with others at your table:
• How can I manage my intent and impact?
@helenbevan
@HelenBevan
@helenbevan
@HelenBevan
“Stages of change”
Transtheoretical model of behaviour change
@helenbevan
@HelenBevan
Prochaska, DiClemente & Norcross (1992)
The model is mostly used around
health-related behaviours
•
•
•
•
•
•
•
•
•
•
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
@helenbevan
@HelenBevan
The model is mostly used around
health-related behaviours
•
•
•
•
•
•
•
•
•
•
smoking cessation
exercise adoption
alcohol and drug use
weight control
fruit and vegetable intake It works for
organisational and
domestic violence
HIV prevention
service change too!
use of sunscreens to prevent skin cancer
medication compliance
mammography screening
@helenbevan
@HelenBevan
“Stages of change”
Smoking
@helenbevan
@HelenBevan
I am not aware my
smoking is a
problem – I have no
intention to quit
Prochaska, DiClemente & Norcross (1992)
“Stages of change”
Smoking
I am not aware my
smoking is a
problem – I have no
intention to quit
I know my smoking
is a problem – I
want to stop but no
plans yet
@helenbevan
@HelenBevan
Prochaska, DiClemente & Norcross (1992)
“Stages of change”
Smoking
I am not aware my
smoking is a
problem – I have no
intention to quit
I know my smoking
is a problem – I
want to stop but no
plans yet
I am making plans
& changing things
I do in
preparation.
@helenbevan
@HelenBevan
Prochaska, DiClemente & Norcross (1992)
“Stages of change”
Smoking
I am not aware my
smoking is a
problem – I have no
intention to quit
I know my smoking
is a problem – I
want to stop but no
plans yet
I have
stopped
smoking!
@helenbevan
@HelenBevan
I am making plans
& changing things
I do in
preparation.
Prochaska, DiClemente & Norcross (1992)
“Stages of change”
Smoking
I am continuing to
not smoke.
I sometimes miss it
– but I am still not
smoking
I have
stopped
smoking!
@helenbevan
@HelenBevan
I am not aware my
smoking is a
problem – I have no
intention to quit
I know my smoking
is a problem – I
want to stop but no
plans yet
I am making plans
& changing things
I do in
preparation.
Prochaska, DiClemente & Norcross (1992)
“Stages of change”
Smoking
I am continuing to
not smoke.
I sometimes miss it
– but I am still not
smoking
I have
stopped
smoking!
@helenbevan
@HelenBevan
I am not aware my
smoking is a
problem – I have no
intention to quit
I know my smoking
is a problem – I
want to stop but no
plans yet
I am making plans
& changing things
I do in
preparation.
Prochaska, DiClemente & Norcross (1992)
“Stages of change”
Transtheoretical model of behaviour change
Prochaska, DiClemente & Norcross (1992)
@helenbevan
@HelenBevan
Some questions
• Which stage do most change activities in
health and care focus on?
• Which stage are most people actually at?
@helenbevan
@HelenBevan
90% of the tools available for health and care change
agents are designed for the “action” stage
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
@helenbevan
@HelenBevan
Example - Surgical Checklist
• 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
@helenbevan #SHCRchat
#NHSChangeDay
So what do we TEND to do?
• 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
@helenbevan
@HelenBevan
The single biggest problem
in communication is the
illusion that it has taken
place
George Bernard Shaw
@helenbevan
@HelenBevan
So what SHOULD we do?
• Listen and understand
 appreciate the starting point
 elaborate interests
• Build meaning and conviction in the change
• Roll with resistance (Singh)
 Don’t argue against it
 Encourage elaboration of resistance
• What makes it so hard?
• What would help?
• Build shared purpose
@helenbevan
@HelenBevan
• 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
@helenbevan
@HelenBevan
• 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
Reflection
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?
@helenbevan
@HelenBevan
“Seeing” as a change agent
•
•
•
•
The big picture
Multiple perspectives
The positive intentions of others
Possibility of bad change processes rather than
resistors, blockers and laggards
• Hopeful futures, creative opportunities and
potential
• Multiple paradigms for change (eg, diagnostic and
dialogic)
• See myself in the context of my higher purpose
@helenbevan
@HelenBevan
A 3-word concept
@helenbevan
@HelenBevan
[Shared] purpose goes way deeper than
vision and mission; it goes right into your gut
and taps some part of your primal self. I
believe that if you can bring people with
similar primal-purposes together and get
them all marching in the same direction,
amazing things can be achieved.
Seth Carguilo
@helenbevan #IQTGOLD
@HelenBevan
#NHSChangeDay
Avoiding “de facto” purpose
• What leaders pay attention to matters to staff, and consequently
staff pay attention to that too
• Shared purpose can easily be displaced by a “de facto” purpose:
 hitting a target
 reducing costs
 reducing length of stay
 eliminating waste
 completing activities within a timescale
 complying with an inspection regime
• If purpose isn’t explicit and shared, then it is very easy for
something else to become a de facto purpose in the minds of the
workforce
Source: Delivering Public Services That Work: The Vanguard Method in the Public Sector
@helenbevan
@HelenBevan
@helenbevan
@HelenBevan
@SimonJGuilfoyle Police Inspector and systems thinker
@helenbevan
@HelenBevan
@SimonJGuilfoyle Police Inspector and systems thinker
Police
@helenbevan
@HelenBevan
@SimonJGuilfoyle Police Inspector and systems thinker
Education
@helenbevan
@HelenBevan
@SimonJGuilfoyle Police Inspector and systems thinker
Healthcare
@SimonJGuilfoyle Police Inspector and systems thinker
@helenbevan
@HelenBevan
“Doing” as a change agent
• Create the conditions where everyone
can contribute and do their best
• Join forces with others to create action
• Achieve small wins which create a sense of hope,
self-efficacy and confidence
• Appeal to both the head (logic/planning/data) and
the heart (shared values/purpose, framing,
relationships)
• Make change (and learning cycles from change)
routine rather than an exceptional activity
• Use models, theories and frameworks effectively
#NHSChangeDay #SHCRchat
@HelenBevan
A call to action
• Create shared purpose for
improving the quality of care
• Work out how to rock the boat
and stay in it
• Build your own self-efficacy
@helenbevan
@HelenBevan
Coming soon………
@helenbevan
@HelenBevan
Outwitted
He drew a circle that shut me out Heretic, rebel, a thing to flout.
But Love and I had the wit to win:
We drew a circle that took him in.
Edward Markham
@helenbevan
@HelenBevan