October Sky

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October Sky
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October sky

• Count the number of PDSA cycles
• What did you observe about the process of
  testing?
• What did you observe about the team?
• What else?

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Change and learning approachKey Components

• Shared goals and outcomes
• Aim is to close the gap in care by testing and
  implementing changes
• Interdisciplinary learning
• Peer and colleague interaction
• Shared problem solving
• careful preparation and organization by the
  leaders are essential for success

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Change and learning ApproachProcess

• Learning session
• Action period
• Try changes
• Measure
• Share and communicate amongst the
  teams/sites/organizations
• Learning session
• Share and learn from each other
• Storyboards, run charts, data, PDSAs, changes
  tried
• Action period
• Try changes
• Measure
• Share and communicate amongst the
  teams/sites/organizations

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Change and learning Approach

• How can we apply what we have learned from the
  collaboratives to the difficult work of
  implementing IHNs

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Engagement Building the IHN team
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What are the principles which can guide
engagement?

• What are the challenges/barriers you have faced
  in engaging different groups?
• Table
• Large group
• What principles can guide engagement?

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Exercise

• ID patients, caregivers, providers, community
  groups involved in care. For each
• what views and issues will be positive, driving
  forces for the changes?
• what views and issues may be barriers to
  engagement and/or change? how will you address
  these?

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Change Management A Vital Tool for Developing
Successful IHNs

• Jack Silversin, DMD, DrPH
• Amicus, Inc
• Cambridge, Massachusetts

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Leading Change Takes Courage
There is nothing more difficult to take in hand,
more perilous to conduct, or more uncertain in
its success than to take the lead in the
introduction of a new order of things because the
innovator has for enemies all those who have done
well under the old conditions, and lukewarm
defenders in those who may do well under the new.
Nicolo Machiavelli - 1505
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Approaching Change

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Successful Change Appeal to Head and Heart

• Behavior change happens mostly by speaking to
  peoples feelings. This is true even in
  organizations focused on analysis and
  quantitative measurement, among people who think
  of themselves as smart in an MBA sense. In highly
  successful change efforts, people find ways to
  help others see the problems or solutions in ways
  that influence emotions, not just thought.

- John Kotter in Change or Die, Fast Company, 5/05
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Successful Change Management

• Address both technical and adaptive aspects of
  the change
• 7.

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Integrating Care An Adaptive Challenge
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Adaptive change is distinct from technical
change to which the application of existing
know-how and the organizations current
problem-solving processes is useful. These are
not sufficient when confronted with adaptive
change.
Ronald Heifetz and Donald Laurie The Work of
Leadership. Harvard Business Review, Jan-Feb
1997
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Two Kinds of ProblemsRonald Heifetz

• 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 deep values)
• Solution requires learning and a new way of
  thinking, new relationships

• Technical
• Problem is well defined
• Solution is known can be found
• Implementation is clear

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Not Either/Or

• Most changes have both technical and adaptive
  aspects
• Integrating care
• Technical aspects different patient flow, care
  provided at different site
• Adaptive aspects giving up control, new
  relationships, money moves to different
  providers, greater transparency

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Real Loss Overshadows Potential Benefits

• People cannot see at the beginning of an
  adaptive process that the new situation will be
  any better than the current situation.
• What they do see clearly is the potential for
  loss.
• - Ron Heifetz

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The Challenge of Adaptive Work
Disequilibrium
Limit of tolerance
Adaptive challenge
PRODUCTIVE RANGE OF DISTRESS
Threshold of learning
Time
Heifetz, Ronald A. and Marty Linsky. Leadership
on the Line, Harvard Business School Press, 2002,
p 108
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Adaptive Change for Members of IHNs

• What are some of the significant adaptive
  challenges associated with implementing IHNs
• For you?
• For front line IHN facilitators?
• For IHN team members?

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Successful Change Management

• Address both technical and adaptive aspects of
  the change
• Help others get the urgency for change

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Establishing a sense of urgency is crucial to
gaining needed cooperation. With complacency
high, transformation usually fails because few
people are even interested in working on the
change problem.People will find a thousand
ingenious ways to withhold cooperation from a
process that they sincerely think is unnecessary
or wrongheaded.
John Kotter, Leading Change, 1996
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The Status Quo is Like Gravity

• The invisible hold of the status quo is very
  strong
• The case for change has to be compelling if it is
  to move others to take action

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Communicate Urgency Point to Burning Platform
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Communicate Urgency Show Data
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Communicate Urgency See, Feel, Change
See, Feel, Change vs. Think, Analyze, Change
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See, Feel, Change Approach

• Create a dramatic, compelling, eye catching,
  shocking experience
• INCREASE optimism, trust, collaboration,
  excitement and other positive emotions
• REDUCE complacency, fear, anxiety, cynicism,
  exhaustion and other negative emotions

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Successful Change Management

• Address both technical and adaptive aspects of
  the change
• Help others get the urgency for change
• Develop a shared picture of the future

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Context for Change is Essential

• Vision
• Picture of the future
• Desired state
• Overarching aim
• Shared destination a place were going together

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Value of Shared Vision

• Conversations to develop vision allow difficult
  issues and divergent perspectives to be aired
• The vision aligns priorities
• A good vision taps into shared aspirations,
  creates pull toward a desired future state
• Clarifies whats in it for us what makes it
  worth the risk, pain, loss associated with change

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Challenges to Having Vision that Is Shared

• Time spent developing shared vision seen as
  touchy-feely
• Process is often superficial conducted as a
  exercise with a narrow purpose (e.g., for PR)
• Little connection between vision on paper and
  daily life
• No clear plan or method for achieving the vision

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Seek and Build on Shared Interests
Bs Interests
As Interests

• SHARED INTERESTS
• Commitment to patients
• Best use of resources
• Pride in what were doing

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Successful Change Management

• Address both technical and adaptive aspects of
  the change
• Help others get the urgency for change
• Develop a shared picture of the future
• Build visible sponsorship

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Three Change Roles

• Leadership with authority
• Sponsors
• Formal leaders who hold others accountable to get
  on with change. I believe we need to do this.

• Leadership with informal authority
• Change Agents
• Use expertise and interpersonal skills to support
  change. Work with sponsors and implementers

• Champions
• Opinion leaders/respected peers. Not part of
  management

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Significant Barrier to Change

• Sponsor passes off to agents

Sponsor moves on to other priorities
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What Effective Sponsors Do

• Demonstrate personal commitment to change
• Publicly and privately speak in favor of the
  change
• Be a role model and among the first to adopt the
  new way
• Align resources with the change
• Provide encouragement and acknowledgment to those
  who get on with change
• Hold all accountable for engaging in the change
  process
• Stay involved not back off when challenged or
  lose focus

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Successful Change Management

• Address both technical and adaptive aspects of
  the change
• Use data and see/feel approaches to help others
  understand urgency for change
• Develop a shared picture of the future
• Build visible sponsorship
• Engage those affected through merit-based
  decisions

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Balance Engagement with Time Constraints

• You cant impose anything and expect others
  will be committed to it.
• - Ed Schein

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Engage Others in Fair Process

• People care about outcomes (and do act in ways
  consistent with self-interest)
• People also care about process. When they
  perceive a process is fair, they accept and
  support decisions/actions not in their
  self-interest
• Bottom line Outcomes matter, but no more than
  the fairness of the processes that produce them.
  
• Fair Process Managing in the Knowledge Economy,
  W. Kim and R. Mauborgne, Harvard Business Review,
  January 2003

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Setting up a Fair Engagement Process

• Get clear what, if any, givens (not amenable to
  change) need to be on the table
• Define what is open for input what can be
  influenced or changed based on input
• Determine how the decision will be made,
  including who will make it
• Plan how you will explain the decision and why
  input was or wasnt used

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Carrying out Fair Engagement Process

• Communicate any boundaries or limitations and
  what is open to input
• Explain the criteria that will be used to
  evaluate input and who will make the decision
• Allow for a fair hearing of all points of view
• Exam the merits of ideas/suggestions relative to
  the criteria already communicated
• Make decision based on the merit of ideas
• Close the loop and communicate decisions and
  rationale to those whose input you sought

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Successful Change Management

• Address both technical and adaptive aspects of
  the change
• Help others get the urgency for change
• Develop a shared picture of the future
• Build visible sponsorship
• Engage those affected through merit-based
  decisions
• Clarify reciprocal expectations (a new compact)

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Compact

• Expectations of professional life in the health
  system that are
• Unstated yet understood
• Reciprocal
• The give
• The get
• Mutually beneficially
• Set up by and reinforced by society and all
  parties involved

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Traditional Physician Compact
GIVE
GET
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Clash Of Old Compact And Imperatives
Traditional Promise
Imperatives

• Coordinate/integrate care
• Improve safety/quality through standard care
• Implement electronic record
• Provide service be patient-focused
• Improve access
• Retain quality staff

• Autonomy for clinical decisions
• Little or no intrusion from government
• Entitlement

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Proactively Develop New Expectations

• When old deal crumbles without conversation,
  anger and frustration result

• Dialogue about what is changing and why
  accelerates support for new deal, new behaviors

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Compact as Tool to Address Adaptive Challenges

• Deep conversation facilitates letting go
• Re-sets expectations thereby building capacity
  for more change
• Forces conversation about shared view of current
  reality and a shared destination
• Reciprocal accountability matures the
  relationship

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Successful Change Management

• Address both technical and adaptive aspects of
  the change
• Help others get the urgency for change
• Develop a shared picture of the future
• Build visible sponsorship
• Engage those affected through merit-based
  decisions
• Clarify reciprocal expectations (a new compact)
• Maximize alignment and consistency

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Consistency

• Mouth, feet and wallet - all go in ONE direction

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Build Consistency

• Align resources with the change
• People
• Time
• Equipment
• Materials
• Education
• Make the right way the easy way
• Reward (tangible and intangible) those who
  change or ensure they are not penalized
• Provide feedback to acknowledge progress or turn
  up the heat

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Use Feedback to Reinforce the Change

• Feedback
• Credible
• Actionable
• That acknowledges progress and encourages further
  action
• Un-blinded (when available and context is right)
  to leverage competitive spirit

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Successful Change Management Addresses Head and
Heart

• Address both technical and adaptive aspects of
  the change
• Help others get the urgency for change
• Develop a shared picture of the future
• Build visible sponsorship
• Engage those affected through merit-based
  decisions
• Clarify reciprocal expectations (a new compact)
• Maximize alignment and consistency

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What will you do next Tuesday?

• Use QI methodology and support IHNs
• Define /refine patient population
• Identify/refine gaps in care
• Write/revise aim statements
• Identify measures and targets to track
• Identify multiple PDSA cycles
• Develop a plan to engage in team members

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How will you support IHNs in change / learning
model

• How learning sessions and action periods may
  apply locally / regionally
• How can IHNs connect and share learning

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What do YOU need

• To support your own work
• To support your teams work
• How Quality Learning Network and Impact BC
  support your work

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Quality Learning Netwrok

• Judy Huska
• Email jhuska_at_impactbc.ca

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