UNDERSTANDING
CHANGE
Updated 07-06-13
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Change
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Types of change
Prerequisites for change
Typical reactions to change
Communicating to different audiences
Organisational learning – learning to learn
Effectiveness of change methods
Cautionary tales – Ferlie & Fitzgerald
Models of the organisation
Prochaska & DiClementes’ model
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Change - Intentionality
May be Planned or Emergent:
• Planned – the product of conscious reasoning and
action
• Emergent – Change unfolds in an apparently
spontaneous and unplanned way – non-linear &
uncontrolled
[Note that intentional change often
has important emergent effects!]
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Change - Temporality
May be Episodic or Continuous:
• Episodic – infrequent, discontinuous and
intentional
• Continuous – ongoing, incremental, evolving and
cumulative
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Change - Depth
May be First, Second or Third Order:
• First Order (Alpha change) – Minor adjustments in
structure or process
• Second Order (Beta Change) – Major reviews of
underlying structure or processes
• Third Order (Gamma Change) – Paradigmatic shift
– complete revision
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Change – Scope & Extent
May be Developmental, Transitional or
Transformational:
• Developmental – 1st order, either planned or
emergent, incremental change that either realigns
or enhances existing resources
• Transitional – Episodic, planned, 1st/2nd order,
seeks to achieve a known desired state
• Transformational – 2nd/3rd order, paradigmatic
change
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Change – Scope & Extent
Improvement of existing situation
Performance
Developmental Change
Time
Transitional Change
Implementation of a known new state
Management of the interim transitional
State over a controlled period of time
Old
State
New
State
Plateau
Transformational Change
Re-emergence
Growth
Emergence of a new state, unknown
Until it takes shape, often out of the death
Of the old state – time period not easily
controlled
Decay / Chaos
Death
Birth
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Prerequisites for successful change
...and effects when one is missing!
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2.
3.
4.
2
1
4
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Bottom of ‘In-tray’
Pressure for change
Capacity for change
A clear shared vision
Actionable first steps
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Anxiety & frustration
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Fast start
fizzles out
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Haphazard efforts
& false starts
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Reactions to Change
D
E
G
R
E
E
O
F
C
H
A
N
G
E
ACCEPTANCE ‘I must change’
RESISTANCE ‘We must change’
AVOIDANCE ‘They must change’
AWARENESS ‘The NHS
must change’
APATHY
‘The world is always
changing’
INVOLVEMENT
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Communicating with different
audiences [1]
Communicating the change
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20 – 25% Late Adopters
Interested but ... “Wait and see”
20 – 25% Skeptics
Wait and ... “I told you so!”
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20 – 25% Early Adopters
Very interested, willingly join
10 – 15% Champions
And Pioneers
“Let’s get started!”
10 – 15% Active Resistors “Forget it!”
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Communicating with different
audiences [2]
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2
1
1.
2.
3.
Early Adopters – Make/help it happen
Late Adopters – Help/let it happen
Skeptics – Let it/stop it happening
1. Inform – Information organisation,prioritisation & presentation
2. Construct an argument – Enlist support of [1] above
3. Persuade and motivate – Maybe communicate costs of resistance
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Communicating with different
audiences [3]
More
Less
Make it happen...
Commitment – will make
systems change to make it
happen
Enrolment – will do
whatever can be done
within existing systems
Help it happen...
Collaboration – Does
everything expected and more
Compliance – Does
what’s expected and no
more
Let it happen...
Benign apathy – Is it 5
o’clock yet?
Grudging compliance –
Sees no benefit, wants no
change. Not ‘on board’.
Against it happening...
Non-compliance – ‘I won’t do
it and you can’t make me!’
Sabotage – Propaganda,
subterfuge or active
hostility
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Communicating with different
audiences [4]
Influencer
Against it
happening
Allow it to
happen
Help it
happen
Make it
happen
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2
3
4
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Organisational learning
• Single-loop learning – Learning how to improve the
status quo – 1st order incremental learning. The most
prevalent form of organisational learning.
• Double-loop learning – Changing the conditions and
assumptions within which single-loop learning takes
place.
• Deutero-learning – Learning how to learn. Metalearning, directed at the learning process itself.
Improves both single and double loop learning.
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Learning Quadrant
Unaware
Unconscious Incompetence
Unconscious Competence
Old, faulty habits go unnoticed
Over-learning, faulty habits accumulate
Old Behaviour
New Behaviour
Conscious Incompetence
Conscious Competence
Increased Arousal
Mindful Practice
Aware
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Challenges for change facilitators...
Unconscious Incompetence
A
T
Awareness
Conscious Incompetence
A
T
Accommodation
A
Conscious Competence
T
Assimilation
A
Unconscious Competence
T
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What’s the evidence?
What strategies are more or less
effective in helping change the
practice of health care
professionals?
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Mostly effective (1)
Decision support (‘expert’) systems providing
timely, relevant, evidence based information
e.g. computer ‘prompts’ that appear during a
consultation (but computer systems can be
cumbersome and produce impractical
recommendations)
Locally produced and ‘owned’ protocols
i.e. locally relevant, locally derived, reflect local
priorities (outcomes are better when standards
professionals are judged by are their own)
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Mostly effective (2)
Interactive education
• Hands on methods structured around clinical
problems
• Learning that clearly links the needs of the service
with improved team working Mostly effective (1)
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Sometimes effective
Audit and feedback, only when the health
professional:
• Accepts that their practice needs to change
• Has the resources and authority to implement
change
• Feedback is offered in ‘real time’ – not
retrospectively
Client led strategies
• Evidence based leaflets for clients
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Largely Ineffective
Didactic education
Distribution of written guidelines, because:
• They remain unread, misunderstood or
decontextualised
• Lack of confidence in recommendations
• Fear (of legal, client pressure, loss of income)
• Lack of skill
• Inadequate resources
• Failure to remember (old habits die hard!)
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Implementing Change – cautions from
Ewan Ferlie and Louise Fitzgerald (1)
Finding one
• There is no strong relationship between the
strength of the evidence and the rate of adoption
of change
Implication
• Linear models of implementation are seriously
misleading and are likely to lead to significant
implementation problems
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Implementing Change – cautions from
Ewan Ferlie and Louise Fitzgerald (2)
Finding two
• Scientific evidence is in part a social construction
as well as ‘objective data’
Implication
• There is no such entity as ‘the body of evidence’
but rather ‘competing bodies of evidence’
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Implementing Change – cautions from
Ewan Ferlie and Louise Fitzgerald (3)
Finding three
• There are different forms of evidence
differentially accepted by different individuals and
different groups
Implication
• Intergroup issues need to be addressed –
different groups coming together in a learning
environment outside of daily routine
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Implementing Change – cautions from
Ewan Ferlie and Louise Fitzgerald (4)
Finding four
• Specific organisational and social factors
influence the path and outcome of change
Implication
• The most effective implementation strategies
combine top-down pressure and bottom-up
energy
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Implementing Change – cautions from
Ewan Ferlie and Louise Fitzgerald (5)
Finding five
• The upper tiers of NHS management, purchasers,
R&D play a marginal role only in change process
Implication
• There is a need to acknowledge that change is
embedded within the professions themselves
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Evidence based change – the
organisation as machine
The 4-stage framework (Sackett & Haines)
Stage 1 – Formulation of
answerable questions,
demanding analytical skills,
an awareness of gaps in
knowledge and a compelling
motivation to do something
about them
Stage 2 – The search for the
best evidence which
requires selection of the
most appropriate sources of
information, their
systematic investigation
and the application of IT
competencies to the full
range of available data
Stage 3 – Critical appraisal
of the evidence. Calling for
rigorous scientific testing of
the accuracy and diagnostic
validity in the literature and
data, with the help of
statistical competencies and
logical discrimination
Stage 4 – The decisions to
apply the conclusions to
patients healthcare, which
demand the integration of
the evidence and expertise
to produce a soundly based
judgement of treatment
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Experience based change – the
organisation as complex system
• Enabling reflexivity within the system
• Enabling the system to formulate a common
language for shared challenges
• Enabling the system to value pluralism and
tension
• Acknowledging that everybody has ‘part of the
truth’ and there are ‘many truths’
• Not trying to reduce many views to one view
• The process of identifying views is part of the
process of identifying a new, and perhaps shared,
future
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