understanding change - Serenity Programme

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Oct 19, 2013 (3 years and 7 months ago)

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UNDERSTANDING

CHANGE


Updated
07
-
06
-
13

SERENE.ME.UK/HELPERS/

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SERENE.ME.UK/HELPERS

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SERENITYPROGRAM

SERENITY.PROGRAMME

Contacts

3



Types of change



Prerequisites for change



Typical reactions to change



Communicating to different audiences



Organisational learning


learning to learn



Effectiveness of change methods



Cautionary tales


Ferlie

& Fitzgerald



Models of the organisation



Prochaska &
DiClementes
’ model



Change

4

Change
-

Intentionality

May be
Planned

or
Emergent
:



Planned



the product of conscious reasoning and
action


Emergent



Change unfolds in an apparently
spontaneous and unplanned way


non
-
linear &
uncontrolled



[Note that intentional change often

has important emergent effects!]

5

Change
-

Temporality

May be
Episodic

or
Continuous
:



Episodic



infrequent, discontinuous and
intentional


Continuous



ongoing, incremental, evolving and
cumulative

6

Change
-

Depth

May be
First
,
Second

or
Third Order
:



First

Order

(Alpha change)


Minor adjustments in
structure or process


Second

Order

(Beta Change)


Major reviews of
underlying structure or processes


Third

Order

(Gamma Change)


Paradigmatic shift


complete revision

7

Change


Scope & Extent

May be
Developmental
,
Transitional

or

Transformational
:



Developmental



1
st

order, either planned or
emergent, incremental change that either realigns
or enhances existing resources


Transitional



Episodic, planned, 1
st
/2
nd

order,
seeks to achieve a known desired state


Transformational



2
nd
/3
rd

order, paradigmatic
change

8

Change


Scope & Extent

Time

Performance

Developmental Change


Improvement of existing situation

Transitional Change


Implementation of a known new state

Management of the interim transitional

State over a controlled period of time

Transformational Change


Emergence of a new state, unknown

Until it takes shape, often out of the death

Of the old state


time period not easily

controlled

Old

State

New

State

Birth

Growth

Plateau

Decay / Chaos

Death

Re
-
emergence

9

Prerequisites for successful change

...and effects when one is missing!

1

2

3

4

1.
Pressure for change

2.
Capacity for change

3.
A clear shared vision

4.
Actionable first steps

2

1

3

2

3

4

1

3

4

2

1

4

Bottom of ‘In
-
tray’

Anxiety

&

frustration

Fast

start

fizzles

out

Haphazard

efforts

&

false

starts

10

APATHY

‘The world is always

changing’

AWARENESS

‘The NHS

must change’

AVOIDANCE

‘They must change’

RESISTANCE

‘We must change’

ACCEPTANCE

‘I must change’

INVOLVEMENT

D

E

G

R

E

E



O

F


C

H

A

N

G

E


Reactions to Change

11

Communicating with different
audiences [1]


20


25% Early Adopters

Very interested, willingly join

Communicating the change


20


25% Late Adopters

Interested but ... “Wait and see”


10


15% Champions

And Pioneers

“Let’s get started!”


10


15% Active Resistors “Forget it!”


20


25% Skeptics

Wait and ... “I told you so!”

1

2

3

12

Communicating with different
audiences [2]

1

2

3

1.
Inform



Information organisation,prioritisation & presentation

2.
Construct an argument



Enlist support of [1] above

3.
Persuade and motivate



Maybe communicate costs of resistance

1.
Early Adopters


Make/help it happen

2.
Late Adopters


Help/let it happen

3.
Skeptics


Let it/stop it happening

13

Communicating with different
audiences [3]

Make it happen...

Commitment



will make
systems change to make it
happen

Enrolment



will do
whatever can be done
within existing systems

Help it happen...

Collaboration



Does
everything expected and more

Compliance



Does
what’s expected and no
more

Let it happen...

Benign apathy



Is it 5
o’clock yet?

Grudging compliance



Sees no benefit, wants no
change. Not ‘on board’.

Against it happening...

Non
-
compliance



‘I won’t do
it and you can’t make me!’

Sabotage



Propaganda,
subterfuge or active
hostility

Less

More

14

Communicating with different
audiences [4]

Influencer

Against it
happening

Allow it to
happen

Help it
happen

Make it
happen

1

2

3

4

15

Organisational learning


Single
-
loop learning



Learning how to improve the
status quo


1
st

order incremental learning. The most
prevalent form of organisational learning.



Double
-
loop

learning



Changing the conditions and
assumptions within which single
-
loop learning takes
place.



Deutero
-
learning



Learning how to learn. Meta
-
learning, directed at the learning process itself.
Improves both single and double loop learning.

16

Learning Quadrant

New

Behaviour

Aware

Unaware

Old Behaviour

Unconscious Competence


Over
-
learning, faulty habits accumulate

Unconscious Incompetence


Old, faulty habits go unnoticed

Conscious Incompetence


Increased Arousal

Conscious Competence


Mindful Practice

17

Challenges for change facilitators...

Unconscious Incompetence



Conscious Incompetence



Conscious Competence



Unconscious Competence

T

A

T

A

T

A

T

A

Awareness

Accommodation

Assimilation

18

What’s the evidence?



What strategies are more or less
effective in helping change the
practice of health care
professionals?

19

Mostly effective (1)

Decision support (‘expert’) systems providing
timely, relevant, evidence based information

e.g. computer ‘prompts’ that appear during a
consultation (but computer systems can be
cumbersome and produce impractical
recommendations)


Locally produced and ‘owned’ protocols

i.e. locally relevant, locally derived, reflect local
priorities (outcomes are better when standards
professionals are judged by are their own)

20

Mostly effective (2)

Interactive education



Hands on methods structured around clinical
problems



Learning that clearly links the needs of the service
with improved team working Mostly effective (1)

21

Sometimes effective

Audit and feedback, only when the health
professional:



Accepts that their practice needs to change


Has the resources and authority to implement
change


Feedback is offered in ‘real time’


not
retrospectively


Client led strategies


Evidence based leaflets for clients

22

Largely Ineffective

Didactic education


Distribution of written guidelines, because:


They remain unread, misunderstood or
decontextualised


Lack of confidence in recommendations


Fear (of legal, client pressure, loss of income)


Lack of skill


Inadequate resources


Failure to remember (old habits die hard!)


23

Implementing Change


cautions from
Ewan Ferlie and Louise Fitzgerald (1)


Finding one



There is no strong relationship between the
strength of the evidence and the rate of adoption
of change


Implication



Linear models of implementation are seriously
misleading and are likely to lead to significant
implementation problems

24

Implementing Change


cautions from
Ewan Ferlie and Louise Fitzgerald (2)

Finding two



Scientific evidence is in part a social construction
as well as ‘objective data’


Implication



There is no such entity as ‘the body of evidence’
but rather ‘competing bodies of evidence’

25

Implementing Change


cautions from
Ewan Ferlie and Louise Fitzgerald (3)

Finding three



There are different forms of evidence
differentially accepted by different individuals and
different groups


Implication



Intergroup issues need to be addressed


different groups coming together in a learning
environment outside of daily routine



26

Implementing Change


cautions from
Ewan Ferlie and Louise Fitzgerald (4)

Finding four



Specific organisational and social factors
influence the path and outcome of change


Implication



The most effective implementation strategies
combine top
-
down pressure and bottom
-
up
energy

27

Implementing Change


cautions from
Ewan Ferlie and Louise Fitzgerald (5)

Finding five



The upper tiers of NHS management, purchasers,
R&D play a marginal role only in change process


Implication



There is a need to acknowledge that change is
embedded within the professions themselves

28

Evidence based change


the
organisation as machine

Stage 1



Formulation of
answerable questions,
demanding analytical skills,
an awareness of gaps in
knowledge and a compelling
motivation to do something
about them

Stage 2



The search for the
best evidence which
requires selection of the
most appropriate sources of
information, their
systematic investigation
and the application of IT
competencies to the full
range of available data

Stage 3



Critical appraisal
of the evidence. Calling for
rigorous scientific testing of
the accuracy and diagnostic
validity in the literature and
data, with the help of
statistical competencies and
logical discrimination

Stage 4



The decisions to
apply the conclusions to
patients healthcare, which
demand the integration of
the evidence and expertise
to produce a soundly based
judgement of treatment

The 4
-
stage framework (Sackett & Haines)

29

Experience based change


the
organisation as complex system


Enabling reflexivity within the system


Enabling the system to formulate a common
language for shared challenges


Enabling the system to value pluralism and
tension


Acknowledging that everybody has ‘part of the
truth’ and there are ‘many truths’


Not trying to reduce many views to one view


The process of identifying views is part of the
process of identifying a new, and perhaps shared,
future

30