Creating contagious commitment to change Our journey so far

1. Creating contagious commitment to change Our journey so far Catherine Holmes NHS Institute for Innovation and Improvement

2. Today To share our learning around creating change at scale Tell you about our call to action and recruit you to join us Test out a new leadership practice Tap into all of you as a collective resource Enjoy ourselves

3. Building the mobilisation movement for quality and cost improvement What it might take to mobilise our staff, communities and people who use our services at scale to achieve cost and quality improvement Leadership actions we can take to shift power in the system and get the outcomes we seek Strategies for building change on a platform of commitment rather than just compliance How to create a compelling narrative for our quality and cost improvement efforts that builds a sense of urgency and a call for action that results in sustainable change

4. Three things that unite us We are leaders who are called to serve those in need We want to help secure the future of the NHS (and the principles it stands for) by helping to deliver high quality care/support that makes best use of precious resources We are prepared to invest in our own learning because we hope there might be some additional perspective, knowledge, skills and relationships that can help us in this quest

7. Dementia Action AllianceOur 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

8. Why a call to action?Which tradition of change? Organising and mobilising Management of change

9. Which tradition of change? • Organisational behaviour • Leadership and management studies • Clinical/medical audit • Improvement “science” • Academic tradition(s) – 100 years 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 Organising and mobilising

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

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

13. How an “organising” approach can contribute to our quality and cost goals Buildcapacity for change and enable others Motivate and mobilise others to action by connecting with emotions, through values Create a sense of “us” as the platform of a movement for change Build commitment, not just compliance Create focus by identifying the small number of actions that people can commit to Shift power in the system to people who deliver services, people who use services, local communities

14. “Often change need not be cajoled or coerced. Instead it can be unleashed.” Kelman, S. (2005) Unleashing Change. A study of organizational renewal in government, Brookings Institution Press; Washington, D.C

15. 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 Source: NHS Institute for Innovation and Improvement (2009) The Power of One, The Power of Many NHS Institute for Innovation and Improvement 2010

16. 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

17. From the old world to the new world Source: Helen Bevan

18. Five leadership messages to consider In our new world, we need levers for commitment, not just compliance We build commitment to actions, not just outcomes Mobilising for change isn't enough; we need to organise We seek to turn the resources we have into the power we need to win the change we want As quality and cost improvement is here for the long haul, we need to manage our own energies and those of the people around us

19. Challenge no 1 • There is a lot of activity and energy for change....... • Unless that energy is translated into appropriate action that improves outcomes, it counts for nothing • How do we provide a focus and an energy that moves everyone in the same direction?

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

21. On your tables-Think of a social movement you have been involved with –Why did you take part?what were its features?What actions were you required to take?

22. If we want people to take action, we have to connect with their emotions through values values emotion action Source: Marshall Ganz

23. Our goals and our progress

24. Dementia Action AllianceOur 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

25. Our strategy To launch a nationwide “call to action” To work in partnership with the Dementia Action Alliance and other networks and organisations that can make a contribution To engage everyone who can play a part in helping to achieve our goal To move beyond mobilising to organising to make this happen

26. What did we need to agree? • Who we are calling to action • What actions we want them to take • The sources of supportand resources that will be made available to help them in their actions

27. Priority groups to call to action • The clinical decision makers who prescribe and review therapeutic interventions • Those who we want to shift power to (e.g., people with dementia and their carers) • Those who can give voice and advocacy to people with dementia and their carers • Those with authority who can promote and ensure best practice

28. Eight groups to call to action • People with dementia and their carers • Leaders of care homes • GPs and primary care teams • Psychiatrists and mental health teams • Pharmacists • Hospital doctors and multi disciplinary teams • Commissioners of health and social care • Medical Directors and Nurse Directors of acute and mental health trusts/providers

29. Making commitments • We commit to specific actionsthat are measurable, • not vague promises • not just outcomes • Make commitments as simple as possible • “one specific action” • We want to hold people to account to the things that they commit to • When we do it effectively, commitment is much more effective than compliance

30. Establish a clear dialogue and agree joint working practices for reviews with all prescribing partners Take on best practice guidelines for the prescribing of antipsychotic medicationand alternative interventionsor people with dementia. Provide support and sign-posting to alternative resources for people with dementia and their carers I (we) commit to: reviewing the people under my care to identify those who are prescribed antipsychotic medication and working in partnership with my prescribing and other healthcare colleagues to review each individual by 31st March 2012 Community pharmacists: Query every prescription for an antipsychotic for people aged 65 years and over and search for, and audit, all people 65 years and over who have received antipsychotic medication in the last 3 months CALLTO ACTION FOR PHARMACISTS What specific action? What are the main themes for action? Hospital pharmacists: Query every prescription for an antipsychotic for people aged 65 years and over and ensure that discharge information is up to date regarding the actions GPs should take (in line with NICE guidelines)

31. Telling your own story and securing commitment

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

34. If we want people to take action, we have to connect with their emotions through values values emotion action Source: Marshall Ganz

35. And not all emotions are equal......... Action motivators Action inhibitors inertia urgency Overcome apathy anger fear hope isolation solidarity Self-doubt you can make a difference

36. What do we need to do? Tell a story

37. What do we need to do? Tell a story Make it personal

38. What do we need to do? Tell a story Make it personal Be authentic

39. What do we need to do? Tell a story Make it personal Be authentic Create a sense of “us” (and be clear who the “us” is)

40. What do we need to do?(narrative) • Tell a story • Make it personal • Be authentic • Create a sense of “us” (and be clear who the “us” is) • Build in a call for urgent action • Identify the intolerable condition • Outline the nightmare if we fail to act. • Offer hope and • Call people to join us in taking a specific action

41. Ghandi While you listen please consider the following: What values did you hear? What was the nightmare situation he described? How did he offer hope? What choices did he offer? How did he build a sense of us? What action did he ask people to take ?

42. Debrief

43. “How wonderful it is that nobody need wait a single moment before starting to improve the world” Anne Frank, Diary of a Young Girl, 1945

44. How do we create a sense of “us” to build a movement for change in health and healthcare?

45. strong tiesversusweak ties

46. When we 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

47. The pros and cons of a strong tie strategy Advantages Limitations

48. Strong and 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 potentially help achieve our goals

49. Why we need to build weak ties AS WELL as strong ties Weak ties are typically a more effective starting point for influence at scale because they enable us to access large portions of the population, with fewer barriers than strong ties In situations of uncertainty, we have a tendency to revert to our strong tie relationships; yet the evidence tells us that weak ties are much more important than strong ties when it comes to searching out resources in times of scarcity. Our best new ideas about how to deliver more effectively with less - and the most breakthrough innovations of the NHS - will come when we tap into our weak ties History suggests that a weak ties strategy will probably give us the best chance to deliver the scale of improvements we seek in quality and cost in a challenging timescale

50. leadership messages for you to consider The traditional “strong ties” model of spreading change in the NHS offers both strengths and limitations The “weak ties” philosophy underpinning many successful social movements helps us to build common ground between disparate groups and individuals Our best new ideas about how to deliver more effectively with less - and the most breakthrough innovations of the NHS - will come when we tap into our weak ties When, as leaders, we call people to action, we should include diagnostic, prognostic and motivational elements in the framing of the message