1. Insert name of presentation on Master Slide Thursday 20 June 2013 – 4.30-5.30pm Doctors Championing Change Session 1: Your call to engage with quality improvement

2. Guest speaker Dr Jack Silversin International author and speaker. Co-author of Leading Physicians Through Change. Today’s session is chaired by Phil Banfield, Chair of BMA Cymru.

3. Session format Introduction First session – Jack Silversin (20 mins) Question and Answer session (5 mins) Second session – Jack Silversin (15 mins) Question and Answer (10 mins) Final comments and close

4. Jack Silversin www.consultamicus.com Session 1: Your Call to Engage with Quality Improvement

5. Inside Organisations: Islands of Doctor Engagement For the most part, doctor engagement in quality improvement: –Optional –Sporadic, inconsistent –Not necessarily viewed by them as a duty

6. What Is Engagement? Commitment to greater good, curiosity, effort beyond fulfilling minimum requirements. Involvement that has an impact on decisions, builds trust, improves results and deepens commitment to the Trust’s success.

7. Benefits When Doctors Engage In Quality Improvement Contribute knowledge and expertise Have greater commitment to solutions, successful implementation more likely Develop realistic views on current state and need for improvement Develop a greater appreciation for interaction among parts Develop greater ownership for the organisation’s quality agenda and performance Develop greater trust in colleagues on improvement projects and respect for their views

8. A Few Differences Between Managers’ and Doctors’ Worlds Doctors Focus on individual patient Seek solutions – quickly Have low tolerance for process, ambiguity View cost/business – as someone else’s issue Likely to spend entire career in one Trust Managers Focus on populations – rarely meet individual patients Have longer term outlook Work with complexity, insolvable issues and political agendas Controlling cost is essential to job success Spend relatively short time in any one post

9. Different Worldviews Contribute To Wobbly Relationships Fragile, distrustful relationships Not “on same page” Doctor scepticism of motives or that change is really needed Managers and doctors both take actions perceived by the other to be driven by self- interest Pool of goodwill is shallow Poor relationship erodes doctor willingness to engage

10. Interactions and Transactions Over Time Create a Dynamic Dance as metaphor Both parties in a dynamic partnership What one does affects the other Years of specific behaviours become ingrained as a pattern Individual steps may not be conscious Credit: Press Association.

11. Examples of the Dance in Motion 1.Managers view Trust finances as their domain keeping doctors distance from those issues. Doctors focus on patient care. As a result, business literacy among doctors low and they can be sceptical that change is necessary. 2.Managers “look the other way” when doctor behaviour is disruptive or abusive. Low accountability reinforces doctors’ view that such behaviour is acceptable. End result is management judgment about, and frustration with, outlier doctors.

12. What Else Gets in the Way of Authentic Engagement? On doctors’ part Cynical that their input makes any difference. Experience is that input goes into “black hole” Reluctance to delegate authority to leaders who can speak for them Many other demands on time and attention When adopting improvement is “elective,” why bother to invest time and effort? On Managers’ part Different definitions of engagement. Is asking for input the same as handing over control? Need for timely decisions makes lengthy process to collect input impossible. Consensus decisions, which doctors prefer, sometimes isn’t practical Little or no success with an efficient process for collecting and using input

13. Higher Levels of Engagement Will Take Changes in Current Dynamic If doctors not engaged in quality improvement – have they been “allowed” to opt out? Are clinical leaders in post, respected and able to speak for other doctors? Do they foster engagement in improvement? Do managers want actively engaged doctors or only when issue is narrowly defined? Bottom line is that higher levels of engagement likely means change for all

14. A Helpful Perspective on Change Technical Problem is well defined Solution is known can be found Implementation is clear Adaptive Challenge is complex To solve requires transforming long-standing habits and deeply held assumptions and values Involves feelings of loss, sacrifice (sometimes betrayal to values) Solution requires learning and a new way of thinking, new relationships Those with problem must be those who develop solutions

15. iPhone = Easily Adopted Technical Change Technical because easy to integrate into daily life (not because it’s technological) No angst or challenge to personal identity Adoption is intuitive or similar to other changes we’ve made. Past experience provides a “road map” or sense for how it works (there’s always the Genius Bar – someone does know what to do)

16. Adaptive Challenge

17. Why Adaptive? Using the checklist challenges existing behaviour patterns and status hierarchy in the operating theatre Calls for different relationships. “Confirm all have introduced selves by name and role.” Techs, nurses cannot be deferential regarding steps in process; to safeguard patient they have a duty to challenge the surgeon if need be Represents several challenges to surgeon autonomy and status

18. Much of Quality Improvement Represents ADAPTIVE Change Guidelines and protocols impinge on doctor autonomy – a deeply held, traditional value Real teamwork means doctor is “on the team, not above it” Care coordination means doctors must show deference to views of other clinical or non- clinical staff Putting patients at center leaves some doctors feeling “doctor at bottom”

19. Adaptive Challenge Summary Takes longer than technical work Involves changing hearts and minds Incompetence must be tolerated as new competencies are developed Requires experimentation Is risky to lead Generates disequilibrium, distress and work avoidance

20. “ ” The most common cause of leadership failure is treating an adaptive problem with a technical fix. - Ronald Heifetz Technical fixes Incentives or compensation Reorganization Merger (without culture change) Promulgating new vision statement Placement of hand sanitizing solution Adaptive solutions Giving authority to solve problems to the implementers – e.g., empower task force to develop solutions Discussion that allows respectful airing of difference Bringing conflict to the surface and constructively resolving it

21. Q&A session (1) Dr Jack Silversin Chaired by Phil Banfield Please send us your questions and comments using the Q&A panel on WebEx or tweet them with #1000lives @1000livesplus

22. 1.Clear the air and build trust – share perspectives and value differences 2.Respond to basic, legitimate needs doctors express 3.Make a case for change that is clear, compelling and urgent 4.Be clear what you mean by the term “engagement” Four Foundations for Building Doctor Engagement

23. Clear the Air of Old Baggage Residual baggage can undermine trust and engagement Clear the air with facilitated discussion: –How we see ourselves –How we see you –How we think you see us Key insight: What do we do that results in others having an impression of us that is unhelpful?

24. More on Sharing Perceptions and Taking Responsibility Most useful insight participants take away from this activity is that they engage in behaviours (mostly unintended) that create or confirm unhelpful views that others hold of them This activity helps individuals take responsibility and choose different behaviours – ones consistent with helpful relationships BUT, in and of itself, this activity won’t build trust. It opens a pathway for more helpful conversation. Keeping commitments builds trust

25. Old Adage: They Won’t Care About You Until They Know You Care About Them Is invitation to engage real or offered because, “Frankly…we tried everything else”? If there is scant evidence the Trust cares about doctors quality of practice life, build positive experiences to change that perception. To start, respond to basic “hygiene” factors

26. The Case of “No Scrubs on Monday Mornings” No scrubs at the very time most needed Operating theatre staff conclude the organisation doesn’t care about them after making multiple attempts to remedy the situation The surgeons were very suspect of managers’ subsequent requests for their involvement What are the “no-scrubs-when-needed” issues in your institution? What “hygiene factors” should management respond to?

27. Unacknowledged risk in status quo Doctors’ presumed “pain,” & uncertainty of change Is The Need for Change Clear, Compelling and Urgent?

28. Productive range of distress Threshold of learning Limit of tolerance Time Disequilibrium Adaptive challenge Heifetz, Ronald A. and Marty Linsky. Leadership on the Line, Harvard Business School Press, 2002, p 108 Distress and Adaptive Change

29. Making Others Uncomfortable is NOT Easy Too often leaders see their role as protecting others from harsh realities “Asbestos boots” handed out during difficult times – any sense of burning platform is extinguished with reassurance, playing down the danger or by withholding information

30. Disengagement and Heat: Two Scenarios Disengagement because there is NOT enough “heat” or urgency conveyed. Need to connect dots for others Disengagement because there is TOO MUCH heat; turbulence, constant change can overwhelm The result is the same: lack of attention to organisational issues, disengagement

31. Dial UP Heat If Sense of Urgency Not Shared If a situation keeps you up at night – why isn’t it keeping others up? What stand in the way of others really sensing the urgency you feel? Demonstrate the cost of doing nothing exceeds the pain and uncertainty of change Make the invisible visible

32. Make it clear you understand and acknowledge feelings – including frustration, distress, loss Simplify and clarify –There might be a technical solution that alleviates stress –Chunk the work into pieces that seem do-able Add resources or slow down a process –Extend deadline, offer training or other support such as temporary extra help – Put more of your own time in, put more attention on the issue Heat Can, and Sometimes Must Be, Dialed Back

33. “What Does Engagement Mean to You?” “We tell them what we expect them to do!” “We ask for input…then do what we think is best.” “When we doctors share our opinions we expect to see those show up in the final decision. Otherwise, why ask me? I have a full plate already.”

34. Degrees of opportunity for doctor input Wide openLimited Focus on “how” of implementation – not the “what.” Get engagement in the “how” Listen non-defensively and with empathy Provide information Arrange demo/talk to other users Ask formal leaders to demonstrate support Focus on benefits to those changing Listen non-defensively and with empathy Use fair process to make transparent, merit-based decisions Engagement Boundaries Criteria Opportunities Process Explanation of decision Expectations made clear Engagement Will Mean Different Things in Different Circumstances None Tell it like it is. Circumstances or agency beyond our control has imposed expectations/rules Listen with empathy Explain benefits to adoption of the change Be prepared that there will be push-back if case for change not well made or understood

35. When There Are Opportunities for Input – Employ Fair Process “ ” — W. Chan Kim and Renée Mauborgne Harvard Business Review, Jan 2003 Outcomes matter, but no more than the fairness of the processes that produce them.

36. Q&A session (2) Dr Jack Silversin Chaired by Phil Banfield Please send us your questions and comments using the Q&A panel on WebEx or tweet them with #1000lives @1000livesplus

37. Readings 1. Heifetz, R. and Linsky, M. Leadership on the Line. Harvard Business School Press, 2002 2. Kornacki, M.J. and Silversin, J. Leading Physicians through Change: How to Achieve and Sustain Results, 2 nd edition, American College of Physician Executives, 2012 3. Kotter, J. Leading Change. Harvard Business School Press, 1996 4. Kotter, J. and Cohen, D. The Heart of Change. Harvard Business School Press, 2002

38. Closing comments Phil Banfield The slides and audio of this session will be available on the 1000 Lives Plus website shortly: www.1000livesplus.wales.nhs.uk/dcc

39. Next session Thu 11 July – 4.30-5.30pm: Engaging doctors in quality improvement Building trusting relationships and developing a shared vision will support doctors to take the lead on improving healthcare systems This session will also include discussions on the role of the Chief Executive and Boards. Please encourage others to join you.