Support for Innovation and Improvement Learning Series

1
Support for Innovation and Improvement Learning
Series

• Foundations Session 4
• Supporting Quality Improvement
• The Human Dimensions of Change
• Creating a Culture of Improvement
• Presenter
• Valerie Nicol - MA, CCC
• Quality Improvement Advisor Impact BC

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What are we trying to accomplish?

• 1. To increase your awareness and understanding
  of the human dimensions of change.
• 2. To provide knowledge and skills that will
  allow you to engage, empower and enable those you
  collaborate with in any situation.
• 3. To assist you with keeping your focus on what
  can be done today despite any hindrances you
  may encounter.

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The human dimensions of change

• According to the NHS Improvement Leaders Guide on
  Managing the Human Dimensions of Change, the most
  commonly cited reason for the failure of change
  initiatives is neglect of the human dimensions of
  change.
• The Improvement Guide 2nd Edition states,
  Focusing only on the changes themselves and not
  their effect on people will doom improvement
  efforts.

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Approach to improvement

• The NHS advises an approach to improvement
  comprised of the following
• Set a direction, but be flexible in how you get
  there
• Top down support is needed for bottom up change
• Objectives need to be set and celebrated when
  achieved. Also, recognize that improvement never
  actually ends.
• Planning and monitoring improvement is important,
  while gaining the commitment of people is VITAL.

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Definitions of change

• CHANGE is external and situational The new
  site, the new structure, the new team, the new
  role, the new procedure.
• TRANSITIONAL CHANGE is the internal
  psychological process people go through to come
  to terms with the new situation.
• TRANSFORMATIONAL CHANGE is the combination of
  both external situational change and internal
  psychological change and it can only occur when
  the existing way of doing things no longer works.

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Personal styles

• Everybody has different ways of communicating
  and different styles of working. It is
  particularly important to be aware of these
  differences when transformational change is
  taking place. Failure to account for these
  differences in personal style often leads to
  people being labelled resistant to change
• Identifying people as laggards or resistant to
  change is not helpful as it sets up conflict. A
  more productive approach is to consider that the
  person simply doesnt see how this idea fulfills
  a need and that they may be an early adopter of
  a different idea.

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Understanding others

• There are several models currently in use to
  describe the different ways people relate to each
  other and to the world around them. The
  Myers-Briggs Type Indicator (MBTI) has been
  popular for decades and summarizes people as
  being one of 16 possible types.

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Understanding others

• The model used by the NHS Improvement Leaders
  Guide is by Merrill and Reid. It describes people
  as being one of 4 possible styles

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Understanding others

• According to Merrill and Reid, we have a tendency
  to develop one of these styles over the other
  three, establishing our MAIN style, our BACK-UP
  style and our LEAST USED style.
• A persons main style indicates
• What interests a person
• What is important to a person
• How they behave or act
• The model postulates that knowing someones main
  style enables you to adopt a communication style
  most likely to influence them.

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Engagement

• Improvement depends on the actions of people
  (NHS Improvement Leaders Guide, 2007)
• Engagement is about relationship building. Even
  if you have the most brilliant improvement idea
  ever conceived, little change will occur unless
  you have created a relationship where the other
  person trusts you enough to tell you how they
  honestly feel about it.
• The context for engagement in primary care
  improvement is broad. Potentially, you will be
  engaging your colleagues, physicians,
  leadership, other health authorities, community
  organizations, and PHC partners.

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Engagement/Relationship building skills

• ASK

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Physician Engagement

• The Engagement/Relationship Building slide
  depicts how/where skills relate to each stage of
  the engagement process.
• Tristan Smith is currently working with the BCMA
  specifically in the area of physician engagement.
  
• In addition to creating the Incomplete Guide to
  Engaging Primary Care Physicians, Tristan will be
  working with each Health Authority to engage a
  broader population of family physicians into
  innovative primary care programs.
• If you have any feedback or suggestions regarding
  the Incomplete Guide to Engaging Primary Care
  Physicians, please email Tristan
  tsmith_at_bcma.bc.ca.

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Tools for engaging physicians

• An Incomplete Guide to Engaging Physicians into
  Primary Care Improvement (double click an the
  picture for download) Draft version

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Tools for engaging physicians

• Engaging Physicians in a Shared Quality Agenda,
  Institute for Healthcare Improvement (Innovation
  Series 2007)
• http//www.impactbc.ca/files/IHI_Engaging_Physicia
  ns_White_Paper_2007.pdf

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Respectful inquiry

• Respectful inquiry is essential for successful
  engagement.
• Come from a place of authentic interest in the
  person you are engaging.
• Acknowledge the value of their time before you
  begin.
• Have a few good questions prepared in advance.
• V. Nicol, 2009

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Communication

• Active Listening (also known as Intentional
  Listening) has 4 components
• Observing and reading non-verbal behaviour. Words
  7 of communication, while tone of voice 38
  and body language 55 . Paying attention to the
  93 of non-verbal communication can yield very
  important information about a person.
• Seeking understanding of verbal messages by
  paraphrasing (so you felt encouraged when you
  started to see results) and summarizing (from
  what you have told me, I understand your
  situation to be )
• Listening to the context means to understand
  the whole person in the context of this one
  situation.
• Being aware of your own biases and not reacting
  in case the other person says something you
  disagree with.

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Attending

• Refers to the ways you are present with other
  people both physically and psychologically. The
  microskills of attending are summarized by the
  acronym SOLER
• S face the person Squarely
• O adopt an Open posture (avoid crossed arms and
  legs)
• L Lean toward the other person
• E Maintain good Eye Contact
• R be Relaxed (encourages others to do the same)

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Building trust and rapport

• Its not what you say, its the way that you say
  it
• Louis Armstrong
• Building trust and rapport creating and
  sustaining a relationship of mutual trust and
  understanding.
• Having rapport listening reflectively and
  having body language that indicates your
  interest.
• Rapport is the basis of good communication and is
  a form of influence.

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General tips for good communication

• Uncertainty is more painful than bad news, so
  communicate early and often
• Seek first to understand, then to be understood
• Communicate directly with the people that matter
  preferably face to face
• Make the communication process transparent and
  two-way
• Be honest and tell the truth
• The result of a communication is the response you
  receive, which may be different from what you
  intended
• You are always communicating, even when you think
  youre not. A person cannot NOT communicate and
  behaviour is the highest form of communication
• NHS Improvement Leaders Guide to Managing the
  Human Dimensions of Change p.33

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Encouragement and support

• Challenge people to try new things in subtle ways
  that inspire their creativity and desire to see
  tasks through to completion.
• Create Solutions to fit Needs You have heard
  and understood what the issues are now is the
  time to apply your knowledge, skills and
  expertise to create workable solutions.
• Do not be afraid to innovate!
• As long as you propose things in a collaborative
  manner, (What do you think about trying.) you
  will keep people engaged and interested in
  working with you.
• V.Nicol, 2009

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Negotiation

• Negotiation is a dialogue intended to produce an
  agreement upon courses of action, to resolve
  disputes, to bargain for individual or collective
  advantage, or to craft outcomes to satisfy
  various interests.
• Negotiation is knowing what and/or when to give
  in order to get what you need.

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Managing conflict

• Begin by being curious about the conflict.
  Through the process of learning what transpired,
  participants will feel heard and tensions will
  subside to the point where resolutions can be
  discussed.
• Conflicts tend to be more about people than
  issues, and they consist of two elements
• The relationship between the people involved
• The issue at the centre of the disagreement

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Managing conflict

• The most important thing is to acknowledge the
  conflict rather than avoiding it.
• Listen to understand the differences in the
  parties involved (including your own).
• Ask questions to assist your understanding of the
  goal from both perspectives.
• Seek a solution that incorporates both goals.

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Taking a leadership stance

• In any change process, you will likely be
  challenged by a number of potential distracters
  such as what transpired before you came along,
  preconceived notions of your agenda, and in some
  cases, a general aversion to change.
• No matter what the situation, be prepared to take
  a leadership stance in the engagement process by
  continuously returning the focus of discussions
  to, What can we do TODAY?

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Discussion

• Q Can you share an example of when taking a
  leadership stance has led to a positive outcome
  in the engagement process?

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Discussion

• Q The NHS Improvement Leaders Guide states,
  Many change projects fail, and the most commonly
  cited reason is neglect of the human dimensions
  of change.
• Lack of insight into why people are unhappy with
  the change
• Poor appreciation for the process of change
• Limited knowledge of the tools and techniques
  available to help improvement leaders
• What is your experience?

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Managing transitions

• Change is not the same as transition. Change is
  situational The new site, the new structure, the
  new team, the new role, the new procedure.
  Transition is the psychological process people go
  through to come to terms with the new situation.
  Remember that change is external and transition
  is internal.
• William Bridges

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Managing transitions

• Bridges describes three stages people can be
  expected to experience during a transition
• 1. The Ending acknowledge there are things to
  be let go
• 2. The Neutral Zone everything is in flux the
  old way is done, but the new way is not yet
  established
• 3. The Beginning the new way feels comfortable
  and is now the only way
• Most organizations try to start with a
  beginning, rather than finishing with it. They
  pay no attention to endings. They do not
  acknowledge the existence of the neutral zone,
  and then wonder why people have so much
  difficulty with change. (Bridges, 2003)

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The Process of Letting Go

• Adapted from Kubler-Ross

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The change process

• Common reasons people are hesitant to change
  include
• Poor appreciation of the need for change, or
  considering it less important than other issues
• Poor understanding of proposed solutions, or
  thinking the solution is inappropriate
• Disagreeing how the change should be implemented
• Embarrassed to admit that things could be
  improved
• Lack of trust in a person or organization due to
  past failed change initiatives
• Anticipation of lack of resources

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Helping people change

• Comfort Zone Some people are happy to stay here.
  They dont change and they dont learn
• Panic Zone People feel forced to change. They
  freeze. They will not change and they will not
  learn
• Discomfort Zone People feel uncertain. They are
  most likely to change and most likely to learn

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The discomfort zone

• People need to feel comfortable to enter their
  discomfort zone
• You can help them do this by creating the
  appropriate environment and culture.
• There is mutual respect and support
• There is no blame
• Ask people to question the current system and see
  it from other perspectives (ie Process Mapping
  and mapping the patient journey)-
  www.institute.nhs.uk/improvementleadersguides)
• Creating a positive and compelling view of the
  future
• Provide Access to training and role models
  (champions)
• Provide coaching, feedback and support groups
• Ensure systems and structures are consistent
• See Improvement Leaders Guide to Building and
  Nurturing an Improvement Culture
  www.institute.nhs.uk/improvementleadersguides

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Stages of change Adapted from
Prochaska and DiClemente
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Spreading improvement ideas

• Research has shown that if you engage 20 of a
  population, the rest will follow in time. Keep in
  mind that someone who appears to be a laggard
  or resistant to change on a particular
  improvement idea may be an early adopter of a
  different idea..

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Activities

• When preparing to share improvement ideas, it is
  helpful to consider the following
• Who is the audience?
• What is their prior knowledge?
• Is the timing and location for the activity
  appropriate?
• Have you provided information and activities in a
  variety of learning styles?

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Activities

• Can you share a personal example of a situation
  in which you were a laggard? Please use the
  chatbox to share

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Activities

• When preparing to share improvement ideas, it is
  helpful to consider the following
• See yourself as a laggard (someone who resists
  change)
• Ask the people in your group to describe an area
  in life where they have not adopted something
  most other people have or do. Ask each person to
  explain their reason to a partner.
• Learning takes place when people realize they can
  be early adopters on some things, and actively
  resisting change on others. Nobody wants to be
  dismissed because of their viewpoint, so this
  encourages people to seek understanding of how
  people see things.

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Keep things moving forward

• Its easy to get sidetracked by the multitude of
  issues that crop up in situations of
  transformational change. The following are some
  strategies to keep things moving forward and
  focused on the common goal of improving patient
  and provider outcomes
• Provide clarity of role and purpose
• Set a boundary for respectful communication
  between all participants
• Frequently acknowledge the valuable contributions
  of all parties
• Focus on problems with systems rather than
  people
• Always return the focus of discussion to a common
  goal of improving patient outcomes and
  experiences
• V. Nicol, 2008

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Summary of managing the human dimensions of
change

• Seek to understand the perspectives of other
  people in a respectful manner.
• Develop a range of styles to use when working
  with people. Your way is not the only way.
• Ask open-ended questions, and demonstrate you are
  listening by using Active Listening Skills.
• Create trust and rapport with people by being
  present with them (attending skills).
• Ask for feedback to learn how you are perceived
  by others and to determine how to modify your
  approach (if necessary) to obtain the results you
  seek.
• Actions speak louder than words. Behaviour tells
  you important things about a person. However,
  people are not their behaviour.
• Remember that if you always do what youve always
  done, you will always get what youve always got.
  
• Adapted from NHS Improvement Leaders Guide

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Next steps/Coaching Discussion

• What might be one thing you will do differently
  to consider the human dimension of change in your
  work?
• When will you try this?
• How will you know a change is an improvement?

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Coaching Session

• Interior Health Authority Margie Wiebe
• 1-877-977-0888 code 6585
• FHA/VIHA/VCH/NHA Valerie Nicol
• 1-877-385-4099 or 604-899-2339 code 7865959

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Next Supporting Innovation Improvement Web
Conference

• Please fill out the survey
• The Applications track will be starting on
  November 19th with a focus on Patients as
  Partners. Please see registration information
  below or contact Avril Ullett at
  aullett_at_impactbc.ca
• http//www.impactbc.ca/learningseries/currentoverv
  iew
• Please note that all materials for the
  Foundations track can be found here
• http//www.impactbc.ca/learningseries/resources/se
  condcohort
• Also check out the updated quality improvement
  tools below
• http//www.impactbc.ca/supportinginnovationandimpr
  ovement/tools