Understanding Change

1. UnderstandingChange Updated 07-06-13

2. Contacts SERENE.ME.UK/HELPERS #SERENITYPROGRAM SERENITY.PROGRAMME serene.me.uk/helpers/#SERENITYPROGRAMfacebook.com/serenity.programme This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

3. Change • 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

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: • FirstOrder (Alpha change) – Minor adjustments in structure or process • SecondOrder (Beta Change) – Major reviews of underlying structure or processes • ThirdOrder (Gamma Change) – Paradigmatic shift – complete revision

7. Change – Scope & Extent May be Developmental, TransitionalorTransformational: • Developmental – 1st order, either planned or emergent, incremental change that either realigns or enhances existing resources • Transitional – Episodic, planned, 1st/2nd order, seeks to achieve a known desired state • Transformational – 2nd/3rd order, paradigmatic change

8. Performance Time Change – Scope & Extent 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 Old State New State Plateau 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 Re-emergence Growth Decay / Chaos Death Birth

9. 1 2 3 4 1 2 1 2 2 1 3 4 3 3 4 4 Prerequisites for successful change...and effects when one is missing! • Pressure for change • Capacity for change • A clear shared vision • Actionable first steps Bottom of ‘In-tray’ Anxiety&frustration Faststart fizzlesout Haphazardefforts &falsestarts

10. Reactions to Change ACCEPTANCE ‘I must change’ D E G R E E O F C H A N G E RESISTANCE ‘We must change’ AVOIDANCE ‘They must change’ AWARENESS ‘The NHS must change’ APATHY ‘The world is always changing’ INVOLVEMENT

11. 1 3 2 20 – 25% Late Adopters Interested but ... “Wait and see” 20 – 25% Skeptics Wait and ... “I told you so!” 10 – 15% Champions And Pioneers “Let’s get started!” 10 – 15% Active Resistors “Forget it!” Communicating with different audiences [1] Communicating the change 20 – 25% Early Adopters Very interested, willingly join

12. 1 3 2 Communicating with different audiences [2] • Early Adopters – Make/help it happen • Late Adopters – Help/let it happen • Skeptics – Let it/stop it happening • Inform – Information organisation,prioritisation & presentation • Construct an argument – Enlist support of [1] above • Persuade and motivate – Maybe communicate costs of resistance

13. Communicating with different audiences [3] More Less

14. Communicating with different audiences [4]

15. Organisational learning • Single-loop learning– Learning how to improve the status quo – 1st order incremental learning. The most prevalent form of organisational learning. • Double-looplearning– 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 Unaware Unconscious Incompetence Old, faulty habits go unnoticed Unconscious Competence Over-learning, faulty habits accumulate Old Behaviour NewBehaviour Conscious Incompetence Increased Arousal Conscious Competence Mindful Practice Aware

17. A A A A T T T T Challenges for change facilitators... Unconscious Incompetence Conscious Incompetence Conscious Competence Unconscious Competence 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 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