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Presentation on theme: "UNDERSTANDING CHANGE Updated 07-06-13. SERENE.ME.UK/HELPERS/ #SERENITYPROGRAM FACEBOOK.COM/SERENITY.PROGRAMME 2 This work is licensed under a Creative."— Presentation transcript:


2 SERENE.ME.UK/HELPERS/ #SERENITYPROGRAM FACEBOOK.COM/SERENITY.PROGRAMME 2 This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License SERENE.ME.UK/HELPERS #SERENITYPROGRAM SERENITY.PROGRAMME Contacts

3 3 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 Change

4 4 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!]

5 5 Change - Temporality May be Episodic or Continuous : Episodic – infrequent, discontinuous and intentional Continuous – ongoing, incremental, evolving and cumulative

6 6 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

7 7 Change – Scope & Extent May be Developmental, Transitional or Transformational : Developmental – 1 st order, either planned or emergent, incremental change that either realigns or enhances existing resources Transitional – Episodic, planned, 1 st /2 nd order, seeks to achieve a known desired state Transformational – 2 nd /3 rd order, paradigmatic change

8 8 Change – Scope & Extent Time Performance Developmental Change Improvement of existing situation Transitional Change Implementation of a known new state Management of the interim transitional State over a controlled period of time Transformational Change Emergence of a new state, unknown Until it takes shape, often out of the death Of the old state – time period not easily controlled Old State New State Birth Growth Plateau Decay / Chaos Death Re-emergence

9 9 Prerequisites for successful change...and effects when one is missing! 12 34 1.Pressure for change 2.Capacity for change 3.A clear shared vision 4.Actionable first steps 21 3 2 34 1 3 4 21 4 Bottom of In-trayAnxiety & frustrationFast start fizzles out Haphazard efforts & false starts

10 10 APATHY The world is always changing AWARENESS The NHS must change AVOIDANCE They must change RESISTANCE We must change ACCEPTANCE I must change INVOLVEMENT DEGREEOFCHANGEDEGREEOFCHANGE Reactions to Change

11 11 Communicating with different audiences [1] 20 – 25% Early Adopters Very interested, willingly join Communicating the change 20 – 25% Late Adopters Interested but... Wait and see 10 – 15% Champions And Pioneers Lets get started! 10 – 15% Active Resistors Forget it! 20 – 25% Skeptics Wait and... I told you so! 1 23

12 12 Communicating with different audiences [2] 1 2 3 1.Inform – Information organisation,prioritisation & presentation 2.Construct an argument – Enlist support of [1] above 3.Persuade and motivate – Maybe communicate costs of resistance 1.Early Adopters – Make/help it happen 2.Late Adopters – Help/let it happen 3.Skeptics – Let it/stop it happening

13 13 Communicating with different audiences [3] 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 whats expected and no more Let it happen...Benign apathy – Is it 5 oclock yet? Grudging compliance – Sees no benefit, wants no change. Not on board. Against it happening...Non-compliance – I wont do it and you cant make me! Sabotage – Propaganda, subterfuge or active hostility LessMore

14 14 Communicating with different audiences [4] InfluencerAgainst it happening Allow it to happen Help it happen Make it happen 1 2 3 4

15 15 Organisational learning Single-loop learning – Learning how to improve the status quo – 1 st 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. Meta- learning, directed at the learning process itself. Improves both single and double loop learning.

16 16 Learning Quadrant New Behaviour Aware Unaware Old Behaviour Unconscious Competence Over-learning, faulty habits accumulate Unconscious Incompetence Old, faulty habits go unnoticed Conscious Incompetence Increased Arousal Conscious Competence Mindful Practice

17 17 Challenges for change facilitators... Unconscious Incompetence Conscious Incompetence Conscious Competence Unconscious Competence T A T A T A T A Awareness Accommodation Assimilation

18 18 Whats the evidence? What strategies are more or less effective in helping change the practice of health care professionals?

19 19 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)

20 20 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)

21 21 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

22 22 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!)

23 23 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

24 24 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

25 25 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

26 26 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

27 27 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

28 28 Evidence based change – the organisation as machine 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 The 4-stage framework (Sackett & Haines)

29 29 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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