1. Engaging clinicians and managers to create contagious commitment to change to deliver results in challenging times Caroline Chipperfield 15th September 2011

2. We have 60 minutes !
What is Leadership, Mobilising and Organising and Action
Introduce the five key leadership practices used within a Call to Action to make change happen
How the NHS Institute for Innovation and Improvement’s is calling people to action the NHS

3. A scenario
You are in charge of a trust effort to reduce costs (at an unprecedented scale and pace) by improving quality Where would you start?

4. Where would you start?
create a “burning platform” and imperative for action around quality and cost improvement

5. Where would you start?
create a “burning platform” and imperative for action around quality and cost improvement
develop a strong narrative (story) around how cost improvement is delivered through quality

6. Where would you start?
create a “burning platform” and imperative for action around quality and cost improvement
develop a strong narrative (story) around how cost improvement is delivered through quality
make a clinically relevant case that makes both a rational connection and a connection to values

7. Where would you start?
create a “burning platform” and imperative for action around quality and cost improvement
develop a strong narrative (story) around how cost improvement is delivered through quality
make a clinically relevant case that makes both a rational connection and a connection to values
make it “real” for frontline staff (e.g., 200 patients and £5k per person per year)

8. More than 80% of our ability to save costs depends on clinical decision making
Brent James,
Institute for Healthcare Delivery Research
Intermountain Healthcare
Copyright NHS Institute for Innovation and Improvement

9. Which tradition of change?
Organising and mobilising
Management
of change

10. Which tradition of change?
Community organising, campaigns and social movements
Learning from popular, civic and faith-based mobilisation efforts
Academic tradition – 100 years
Organisational behaviour
Leadership and management studies
Clinical/medical audit
Improvement “science”
Academic tradition(s) – 100 years
Management
of change
Organising and mobilising

11. “Often change need not be cajoled or coerced
“Often change need not be cajoled or coerced. Instead it can be unleashed.”
Whyte (1994: 221) has a similar notion of change and energy being ‘released’ – cross-ref ‘tapping in to sentiment pools to release energy
Kelman, S. (2005) Unleashing Change. A study of organizational renewal in government, Brookings Institution Press; Washington, D.C

13. Compliance Commitment
From the old world to the new world
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 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”)
Source: Helen Bevan

14. How do we create improvement at scale?
The ‘mobilisation’ mindset for improvement
The ‘clinical system’
mindset for improvement
Focus: energy for change
imagination
engagement
moving
mobilising
calling to action
creating the future
Focus: effectiveness and efficiency
metrics and measurement;
clinical systems improvement,
reducing variation,
pathway redesign,
evidence based practice
Draws on Gareth Morgan’s Images of Organisation: the central thesis of this book is that all theories of organisation and management are based on implicit metaphor, and that metaphors play a paradoxical role: they are vital to understanding and highlighting certain aspects of organisations, while at the same time they restrict understanding by backgrounding or ignoring others. (Poggi)
Source: NHS Institute for Innovation and Improvement (2009) The Power of One, The Power of Many
NHS Institute for Innovation and Improvement 2010

15. Deficit based Asset based
Approaches to change
Deficit based
what is wrong?
solving problems
identifying development and improvement needs
gaps and deficiencies to be filled
Asset based
what is right that we can build on?
exploiting existing assets and resources
“positive deviance”
amplifying what works
Source: Helen Bevan

16. Shared understanding leads to
How did the great social movement leaders change the world?
Strategy
what?
Narrative
why?
Shared understanding leads to
Action
Source: Marshall Ganz

17. What is Mobilising and Organising ?
Mobilisation...
It’s like lots of helium balloons going up into the sky
Community organising...
grabs the strings of all of those established through 1.1s
This collective, based on
common values and
relationships
gives you the power (extra resources) to lift you off the ground towards your goal and cause

18. Images from social movements you might be familiar with

19. Achieving Common Purpose through Shared Values and Commitment
A Call to Action is
Achieving Common Purpose through
Shared Values and Commitment

20. What is leadership in a call to action?

21. Leadership is taking responsibility for enabling others to achieve shared purpose in the face of uncertainty
Prof. Marshall Ganz
Harvard Kennedy School

22. The ‘Lone Ranger’ model…
I’m the Leader

23. The “we’re all leaders” model…

24. Empowered Leadership

25. Relational Commitment
Key practices of empowered leadership
DISORGANISATION
Passive
Divided
Drift
Reactive
Inaction
LEADERSHIP
Shared Story
(Public Narrative)
Relational Commitment
(Relationships)
Clear Structure
Creative Strategy
Effective Action
(Measurable)
ORGANISATION
Motivated
United
Purposeful
Initiative
Change 25

26. a skill to motivate others…
Public Narrative is…
a skill to motivate others…
…to join you in action
story of
self
now us

27. Why I am called to do this work

28. our shared EXPERIENCE
reveals
our shared VALUES

29. we frame the urgency and hopefulness necessary to secure commitment and build momentum towards our shared goal

30. Values into action
values
emotion
action
Source: Marshall Ganz

31. OVERCOMES Emotion and action inertia urgency apathy anger fear hope
INHIBITORS
ACTION
MOTIVATORS
inertia
urgency
apathy
anger
OVERCOMES
fear
hope
isolation
solidarity
self doubt
Y.C.M.A.D.
Source: Marshall Ganz

32. Creating a shared commitment
Relationship as Interest Common Interests New Interests
Interests
Interests
Commitment
Resources
New Resources
Common Resources
Relationship as Resource
Resources

33. Compliance Commitment
From the old world to the new world
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 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”)
Source: Helen Bevan

34. strong ties versus weak ties

35. Strong and weak ties When we seek to spread change through weak ties:
When we seek to spread change through strong ties:
we interact with “people like us”, with the same life experiences, beliefs and values
Change is “peer to peer”; GP to GP, nurse to nurse, gynaecologist to gynaecologist
Influence is spread through people who are strongly connected to each other, like and trust each other
IT WORKS BECAUSE: people are far more likely to be influenced to adopt new behaviours or ways of working from those with whom they are most strongly tied
When we seek to spread change through weak ties:
we build bridges between groups and individuals who were 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
our aim is to mobilise all the resources in our organisation. system or community that can help achieve our goals

36. Discretionary effort what we willingly do because we want to
extent to which we are interested and involved in assisting the organisation in accomplishing its goals
an unmanaged and unrealised resource for most organisations
represents a range of performance 30-40% above that which is actively realised by an organisation

37. Work is contractual Effort is personal
Discretionary effort
Work is contractual Effort is personal

38. Creating shared strategy
Turning what you have
Resources
Power
Outcome
Into what you need
To get what you want

39. Resources to improve quality and cost at scale
grow
diminish
Economic resources
diminish with use
money
materials
technology
Natural resources
grow with use
discretionary effort
relationships
commitment
Based on principles from Albert Hirschman, Against Parsimony

40. Power Not a thing, a quality or a trait
The influence created by the relationship between interests and resources
We grow our capacity for example by…
Building relationships with different kinds of people
Building different kinds of relationships with people we already work alongside with
Enabling others to take action by developing leadership and acquiring new skills
Motivating others to act together
Giving voice

41. Change Specific – measurable and clear
Concrete – “real” change that is felt and lived
Significant – challenging and consequential

42. Relational Commitment
Key practices of empowered leadership
DISORGANISATION
Passive
Divided
Drift
Reactive
Inaction
LEADERSHIP
Shared Story
(Public Narrative)
Relational Commitment
(Relationships)
Clear Structure
Creative Strategy
Effective Action
(Measurable)
ORGANISATION
Motivated
United
Purposeful
Initiative
Change 42

45. Dementia Action Alliance Our goal
By 31st March 2012, all people with dementia who are receiving antipsychotic drugs will have undergone a clinical review to ensure that if they are receiving these drugs they are doing so appropriately and that alternatives to their prescription have been considered and a shared decision has been agreed regarding their future care

46. How do we work?
Launched a nationwide “call to action” on 9th June 2011
We work in partnership with the Dementia Action Alliance , other networks and organisations, that can make a contribution
We engage with everyone who can play a part in helping to achieve our goal
We have 8 commitment groups
We move beyond mobilising to organising to make this happen

47. National Taskforce for Dementia and Antipsychotics
National Clinical Director for Dementia
QIPP Lead for Medicines management
Alzheimer’s Society Policy Lead
Dementia Action Alliance Chair
GP lead
Junior Drs Lead
Care Homes Lead
National Clinical Director for Pharmacy
DH Social Care and Dementia Lead
NHS Institute Call to Action support team

48. Junior Doctor Call to Action
The Department of Health and Dementia Alliance
We commit to carefully considering whether or not a prescription for antipsychotic medication is appropriate for someone with dementia who is in hospital and to reviewing the prescription on transfer or discharge from hospital

49. energy.....
One of the most important leadership tasks in the era of quality and cost improvement is to manage our own energies and those of the people around us

50. Four sources of energy Energy Description Intellectual Emotional
Energy of analysis, logic, thinking, rationality. Drives curiosity, planning and focus
Emotional
Energy of human connection and relationships. Essential for teamwork, partnership, alignment and collaboration
Spiritual
Energy of vitality, passion, the future and sense of possibility. Brings hope and optimism and helps people feel more ready and confident to build the future
Physical
Energy of action, making things happen and getting them done. Key part of vitality, maintaining concentration and commitment
Source: adapted from Steve Radcliffe

51. What are the consequences?
Question
Which energies do we use most in our quality and cost improvement efforts?
What are the consequences?

52. What’s wrong with using intellectual energy?
connecting intellect to intellect keeps us in our comfort zone
it isn’t transformational
We will achieve greater results (pace and scale) if we link physical energy to emotional and spiritual energy
In these difficult times, we particularly need spiritual energy

53. Who understood the need for spiritual energy?
“Society becomes more wholesome, more serene, and spiritually healthier, if it knows that its citizens have at the back of their consciousness the knowledge that not only themselves, but all their fellows, have access, when ill, to the best that medical skill can provide.” Aneurin Bevan, founder of the NHS

54. The challenge
 ”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 workforce’s primary motivators for putting extra energy into the change programme”
Scott Keller and Carolyn Aiken (2009) The Inconvenient Truth about Change Management

55. What is the potential for organising in healthcare?
Professionally led healthcare
Patient/ family as consumer/ receiver of care
Clinical professional leads the process, defines the problem and designs the intervention
Work occurs at site determined by professional at a time determined by professional
Collaborative healthcare
Patient/ family active, engaged but still a receiver/ consumer of care
Professional proposes, consults, shares decisions on how to proceed
More power to patient but this is about isolated individuals in a one to one relationship with the system
Citizen
healthcare
Patient*/ family as co-creator, producer of health
May begin with collaborative professional leadership but becomes patient/ family/community led
Communities of patients/ families/volunteers are the main definers and contribute to the intervention with professional input
Jointly determined sites and locations
*Need to change the terminology as the terms such as “patient” or “user” suggests a passive receiver/ consumer of care
Source: adapted from the work of Bill Doherty

56. And as for learning Call to action: mobilising leadership…..

57. We have a choice
“This is the true joy of life, the being used up for a purpose recognised by yourself as a mighty one, being a force of nature instead of a feverish, selfish little clot of ailments and grievances, complaining that the world will not devote itself to making you happy”
George Bernard Shaw