Supporting Adaptive Change: Challenges and Strategies

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Supporting Adaptive Change Challenges and
Strategies

• Jack Silversin
• Amicus, Inc
• www.consultamicus.com

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Broken Squares

• Goal is five squares of equal size
• You can give away pieces
• No verbal communication (talking, other sounds)
• No non-verbal communication (e.g., pointing or
  placing someone elses pieces)
• Everyone must have at least one piece in front of
  them at all times

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Improving Health Care is Technical AND Adaptive
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 Change

• Adaptive
• Challenge is complex
• The transformation of long-standing habits and
  deeply held assumptions and values
• Feelings of loss, sacrifice (sometimes betrayal
  to deep values) are typically part of the journey
• Implementation requires learning and a new way of
  thinking

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

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Not Either/Or

• Many changes have both technical and adaptive
  aspects
• Electronic Health Record
• Technological aspects hardware and software
• Adaptive aspects changes interaction with
  patients, need to adjust interview behaviors

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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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Implications for Your Role as Change Facilitator

• Consider the changes you are supporting in
  primary care in what ways are they technical?
• What are the adaptive aspects that make these a
  challenge to implement and sustain?

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Implementing Change Mystery or Science?
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Keys to Facilitating Change

• Clear vision of the future state
• Change principles to guide your plans and actions
  
• Ability to improvise in face of evolving
  realities and emerging needs especially
  important when the change is adaptive

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Principles for Facilitating Change

• Recognize early adopters differ in significant
  ways from others
• Create pull dont push
• Understand the change from the implementers
  perspective
• Build your own credibility as change agent
• Foster discussions of how the deal is changing
  and why

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Change Adoption Chasm

• Early adopters risk takers

Late adopters risk avoiders
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Insights from Public Health Innovation

• Little sustainability when the program was
  pushed or adopted for narrow reasons (e.g.,
  someone else funded it)
• When pulled in to solve a felt need, program was
  sustained when funding ended

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Create Pull

• 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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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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How to Reduce Work Glove Costs
Same gloves range from 5 to 17
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See, Feel, Change Examples

• Hospital executives shadowing front line staff
• Giving life to incidents of wrong-site surgery
  through patient stories
• Field trips, study tours

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Create Pull

• Clear and compelling vision of the future. A
  picture of a desired destination
• Direct answer to Whats in it for me?

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See the Innovation from Their Perspective

• Relative advantage the degree to which it is
  perceived to be better than current practice
• Compatibility consistency with existing values,
  past experiences and needs
• Complexity difficulty of understanding and use
• Trialability the degree to which it can be
  experimented with on a limited basis
• Observability the visibility of its results

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Diffusion of One Innovation

• Iowa Farmers 1930s. Adoption of new hybrid
  corn seed
• Respected opinion leaders were the early adopters
• The innovation spread it had superior yield,
  results were visible, practice compatible with
  existing ones, no more difficult to plant

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Applicable Lessons

• Dont judge others reactions
• Can the benefits be made transparent?
• Can you link the new behaviors to underlying
  values, commitment to patient care?
• Can positive results from one practice be made
  visible to others?
• Can a trial or bite size piece of the change be
  put into practice and evaluated?

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Enhance Your Credibility as Change Agent

• Credibility has two sources
• Expertise Proven track record, history of sound
  judgment, knowledge, first-hand experience
• Relationships trusted to listen to and work in
  the best interest of others

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Build Credibility

• Dont over-promise, dont exaggerate
• Keep commitment or re-negotiate expectations
• Pilot projects, small steps
• Keep the other persons style in mind
• Bring in expertise that you dont have

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Seek to Understand

• Before presenting your own point of view, it
  would be necessary for you to achieve the other
  speakers frame of reference, to understand his
  thoughts and feelings so well that you could
  summarize them for him. Sounds simple. Try it,
  and you will discover that it is one of the most
  difficult things you have ever tried to do.
• - Carl Rogers

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Compact

• Expectations physicians have 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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NHS England
At the creation of the NHS in 1948, the deal
between doctors and the government was

• The Medical profession
• Accepted govmnt right to decide NHS funding
  level
• Retained clinical autonomy and self-regulation

• The government
• Did not seek to influence clinical decisions
• Handed responsibility for deciding priorities to
  doctors to manage in the privacy of their
  surgeries and clinics

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Clash Of Promise And Imperatives
Traditional Promise
Imperatives

• 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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Make Expectations Explicit

• 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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Emerging Deal The Gives
General Practitioners

• Health System Ministry HAs

• New to improve care and outcomes
• Support to modernize practices
• Recognition of career challenges and value to
  health system
• Coordination of community resources to better
  serve patient needs

• Systematized clinical care
• Managing health of a population
• Engaging in practice modernization
• Openness to relationship with HA

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Emerging Deal The Gets

• Health System
• Stable, engaged primary care work force
• Better value for money
• Better coordination of resources
• Means for ongoing communication and improvement

• General Practitioners
• Better alignment between compensation and work
• Respect for difficult work
• More efficient and effective practice
• Less professional isolation
• Patients share responsibility for their health

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Patients Can Make or Break Emerging Deal

• Former/current patient expectations

Expectations needed to support emerging deal

• Trade off wait time for free-at-point-of-access
  care
• Willing to exert political power to get desired
  results

• Support for rationalizing care
• Engagement in healthy lifestyle, active partner
  in care
• Acknowledge efforts of GPs to modernize

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Conversations About the DealPractical
Application for Change Facilitators

• Help GPs to appreciate that, with new
  expectations of them, there is more
  supportmodernization is proceeding as a 2-way
  street
• Help GPs understand the framework of reciprocal
  and clear expectations and how it can be applied
  to conversations with Health Authority
• Point out how using the framework can build trust
  when both parties make and keep commitments

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More Change Likely Around the Corner