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Leadership and change in health systems

This document discusses leadership and change management in complex health systems. It begins by outlining where change efforts can go wrong, such as weak design and implementation. It then provides guidance on strengthening design through co-design and considering implementation. The document emphasizes that change must be led and managed, occurring through people. It discusses the importance of building commitment to change through sensemaking, communication, and addressing people's values. It also recommends embracing complexity and learning through small wins and feedback loops to increase the chances of success in health system strengthening efforts.

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Leadership & Change in Health Systems ICHS 7 www.hpsa-africa.org @hpsa_africa www.slideshare.net/hpsa_africa Introduction to Complex Health Systems
Change: where do things go wrong? 1.Weak design
Re-design process • How are intervention effects likely to ripple through system (consider the BBs)? • What re-design could – offset negative effects? – take advantage of positive synergies?
In strengthening design, need also to consider: Who to co-design with & how manage the process? How can implementation/change be better managed?
Change: where do things go wrong? 2.Weak change management (implementation)
Causes of failure A poor design and implementation plan A weak enabling environment A case of ignoring red tape and bottlenecks A failure to learn Failure Kusek et al. 2013 Lack of senior management support; not listening to critics; poor communication; lack of stakeholder management plan; poor use of formal & informal networks Failure to admit mistakes; aversion to risk taking
Recognising complexity • Complexity implies unpredictability • Complex challenges require people and organisations to change, often in profound and fundamental ways
Change does not happen by itself has to be led and managed occurs through people and groups
Leadership: Enabling others to face challenges and achieve results under complex conditions
Two key starting points for leaders • Personal reflection: – hopes, aspirations, beliefs, interests, power • Review of past experience: – as influence over other agents – as influence over implementation feasibility
Moving towards shared, inclusive, collective, distributed Leadership
Leadership for complexity 1. Shared sensemaking > collective mindsets to support change 2. Creating connection > relationships that enable change 3. Navigation > learning from innovation & emergent strategies Drath 2003
Commitment planning • Describe the future & publicise the change = the basis for commitment • Commitment planning: – Who must be committed? – What current commitment level? – What changes need and how bring about? (Barnes, 1995)
Planning for commitment change Key agents No commitment (oppose) Let it happen (no active support) Help it happen (need their support) Make it happen (willing to lead) CEO OX Chairman medical staff committee O X Staff member A O X Staff member B O X Consultant C O X Consultant D X O Manager E O X
Change as political negotiation • Select 4-5 most influential stakeholders who impact on change & who you want to influence – Identify potential senior champions and critics • Think about how they will assess success of your proposal & develop a plan to influence them so they judge innovation a success • Use positive support of these agents to influence others (Osborne and Brown, 2005)
Think about the use of power • Planned & imposed change may encourage compliance without commitment • because it fails to provide spaces for the new forms of sensemaking necessary to support the intended changes
• Compliance: you do something because you have to – Do just what is required and no more – Purposively do the wrong thing • Commitment: you want to do something, you believe in it
Power in health systems From top to bottom From bottom to top
Sensemaking • For organisational change to succeed it must involve shifts in shared assumptions and beliefs about how things happen in the organisation and how people act – changes in mindsets of organisational agents (Balogun 2006)
Leading sensemaking • The way managers understand, interpret, create and diffuse sense of the information surrounding strategic change (Rouleau and Balogun 2007)
Pay attention to staff • Ensure early involvement of staff in change process • Help staff face up to change • Work through face to face communication • Listen (and talk) • Be positive in working to gain commitment to change, enabling staff to see opportunities not just threats (Osborne and Brown, 2005)
Build commitment Sensemaking: • What visions? • What messages? • What ideas? How build trust? • What are agents’ natural attractors? (values, behaviours that people and the organisation are drawn towards) • What simple rules? (principles for action)
Advice networks Trust networks Communications networks Visible: the formal organisation Vision, Mission, Structure, Job descriptions, Goals, Strategies, Operating policies complicated Invisible: the informal organisation Power and influence patternsGroup dynamics Impulsiveness Feelings Interpersonal relations Organisational culture Individual needs complex Adapted from Kusek et al. 2013 Tap into the power of: Building commitment
In a complex adaptive system ‘...organisational change is not management induced. Instead, organizational change is emergent change laid down by choices made on the front line’ (Weick 2009: 239)
Plan small wins • Rather than being overwhelmed by the difficulty of bringing about necessary ‘big changes’, break down the change into a series of smaller steps or ‘small wins’ that move towards that change • Eat an elephant bite by bite
• A small win is a concrete, complete, implemented outcome of moderate importance. • By itself, one small win may seem unimportant. • Once a small win has been accomplished, forces are set in motion that favor another small win. • When a solution is put in place, the next solvable problem often becomes more visible. • This occurs because new allies bring new solutions with them and old opponents change their habits. • Additional resources also flow toward winners, which means that slightly larger wins can be attempted. Karl Weick from “Small Wins: Redefining the Scale of Social Problems,” American Psychologist, January 1984
Two types of small wins 1. Actions that can be implemented quickly and successfully, and so build support for change 2. The continuous application of a small action targeting a key constraint to change – and opening up opportunities for longer-term and more radical change
Type 1: • Team building workshop, getting people to know each other, planning new initiative, generating improved short - term work performance Type 2: • Breaking down hierarchical barriers by calling each other by first name, supporting recognition of each other as people, encouraging working together and building trust over the long-term
Benefits of small wins • Reduces fear of change • Clarifies direction • Increases possibility of early successes, which boost support for further action • Helps us to feel good
And… • Can’t pre-plan everything! • Important to encourage learning through doing • In ways that build support and commitment! • Feedback loops matter • Take risks & learn from mistakes
Learning through doing • Apply the PDSA cycle to each small win to provide basis for next cycle of action P (lan) D (o) S (tudy) A (ct)
Identify the problem Design programme interventions Implement and field test Measure and give feedback Have time for review, discussion, revision Implement and field test the revised programme Measure and give feedback, then repeat throughout implementation Adaped from Kusek et al. 2013, p.63
Five rules to increase chances of success 1. Build commitment to getting things done 2. Manage stakeholders: keep your champions close but your critics closer 3. Work with the Informal networks in your organisation 4. Manage processes 5. Learn as implement Kusek et al., 2013
Five simple rules of large scale Health System change 1. Engage individuals at all levels in leading the change efforts 2. Establish feedback loops 3. Attend to history 4. Engage physicians 5. Involve patients and families Best et al. 2013
Copyright Funding You are free: To Share – to copy, distribute and transmit the work To Remix – to adapt the work Under the following conditions: Attribution You must attribute the work in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work). Non-commercial You may not use this work for commercial purposes. Share Alike If you alter, transform, or build upon this work, you may distribute the resulting work but only under the same or similar license to this one. Other conditions For any reuse or distribution, you must make clear to others the license terms of this work. Nothing in this license impairs or restricts the authors’ moral rights. Nothing in this license impairs or restricts the rights of authors whose work is referenced in this document. Cited works used in this document must be cited following usual academic conventions. Citation of this work must follow normal academic conventions. Suggested citation: Introduction to Complex Health Systems, Presentation 7. Copyright CHEPSAA (Consortium for Health Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org www.slideshare.net/hpsa_africa This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no. 265482). The views expressed are not necessarily those of the EC.
The CHEPSAA partners University of Dar Es Salaam Institute of Development Studies University of the Witwatersrand Centre for Health Policy University of Ghana School of Public Health, Department of Health Policy, Planning and Management University of Leeds Nuffield Centre for International Health and Development University of Nigeria Enugu Health Policy Research Group & the Department of Health Administration and Management London School of Hygiene and Tropical Medicine Health Economics and Systems Analysis Group, Depart of Global Health & Dev. Great Lakes University of Kisumu Tropical Institute of Community Health and Development Karolinska Institutet Health Systems and Policy Group, Department of Public Health Sciences University of Cape Town Health Policy and Systems Programme, Health Economics Unit Swiss Tropical and Public Health Institute Health Systems Research Group University of the Western Cape School of Public Health