Inspiring change in the NHS: the five frames

Inspiring
Change
in the NHS:
Introducing the Five Frames

This document is intended to be updated regularly
in order to ensure it is as helpful as possible.
This is Version 1, published on 22 May 2009.
If you have feedback on how it can be improved or if you
have a query or would like further information, please contact:
Annette Neath at annette.neath@institute.nhs.uk
Included within this document is reference to specific tools, including,
but not limited to, the Five Frames and the Organisational Health Index
(“Tools”).All intellectual property rights, including copyright, in and to the
Tools, are the sole property of McKinsey & Company.The Tools may be used
internally by the staff of the NHS, but no other person may use, reproduce,
disclose or distribute the Tools without McKinsey & Company’s express prior
written consent.

Contents
Executive Summary 1
Delivering High Quality Care for All 3
The Five Frames 6
– Introduction
– Quick reference
– Summaries of the Five Frames
Appendix: Examples, tools, evidence, 16
tips and tricks

|
Inspiring Change in the NHS: Introducing the Five Frames
Executive Summary
High Quality Care for All (HQCfA) has set a profound challenge to the NHS.
Achieving the vision set forth in HQCfA will require fundamental changes
in our thinking and in how we work, in our teams and across the entire
system. The current economic climate and our need to plan for the next
Comprehensive Spending Review increase the imperative for change.
In response to the challenges set forth, David Nicholson consulted experts
within and outside the NHS on how to achieve the type of sustainable,
large scale changes that are clearly required. The Four Principles (co-
production, subsidiarity, system alignment and clinical engagement)
are the result of this initial consultation. They represent the guidelines for
the new ways we should work in order to bring about the vision laid out
in High Quality Care for All. The Five Frames provide a way to realise these
new ways of working. They are a powerful model of change, representing
five important areas of consideration for leaders in the NHS.
The NHS Management Board members recognise that this change must
start with them. They have been working through the Five Frames to
identify what they need to change in how they work, and what they can
do to support change across the system. This is not to suggest that the
frames are mandatory or an alternative to on-going activity. NHS leaders
who have already used the Five Frames have built them into their existing
change approaches to gain an additional perspective or more robust
change plans.
This document introduces NHS leaders to the Five Frames, as they consider
what changes may be needed in their parts of the system, and how they
can achieve them.
“Strategies and
processes alone
are not sufficient
to drive the
degree of change
we are seeking…
the NHS should
focus on tackling
the behaviours
and cultures in
the system that
stand in the way
of moving forward
on quality.”
— David Nicholson,
Annual Report 2009
The Five Frames are:
Performance Health:
Change is not just about delivering performance today. It is also
about creating ‘healthy’ organisations and systems which will deliver
performance tomorrow and the day after.
The Discovery Process: Creating deep, sustainable change is not just
about creating an excellent strategy or about redesigning delivery
systems and processes. It is also about changing the mindsets which
underlie behaviours and outcomes.
The Influence Model:
When we plan actions to bring about the desired changes in mindsets
and behaviours in our organisations, we need to make sure that we
create a wide range of initiatives that cover a broad perspective of
change, rather than concentrating on a single ‘type’ of intervention
that will not deliver wide scale change.
Change Architecture:
In designing a change strategy, particularly in a complex system,
we need to plan carefully to make sure that the initiatives are
well-sequenced, occur at the right place in the organisation,
engage stakeholders and are well-understood.
The Benefits Hierarchy: Measuring the success of change interventions
is vital. As well as ensuring that initiatives are on schedule and
milestones are met, and measuring performance as the outcome,
we need to measure organisational and system health and make
sure it is improving.
1.
2.
3.
4.
5.

|

In this document, we present
the Five Frames as a logical set for
thinking about change. However,
as other NHS leaders have done,
you can choose to work with all
five, or with just one or two frames
and fit them into your existing
approach to change.
How to use this
document
• Audience:
The NHS leadership
community – those who
lead change in NHS
organisations and those
who partner with other
organisations to lead
change in the wider health
system.
• Structure:
A summary of each frame is
provided, together with an
appendix which provides
examples, tools, evidence,
tips and tricks.
To learn more:
This document is ‘work in
progress’. We will make further
materials available and offer
learning opportunities. In the
spirit of co-production, we would
very much like to hear from you
on what would be useful. You can
contact Annette Neath at annette.
neath@institute.nhs.uk if you have
a query, want further information,
or would like to suggest support
materials for use with your team.

|
Delivering High Quality
Care for All
What’s the challenge?
High Quality Care for All (HQCfA)
has set out a profound challenge
to the NHS to achieve significant
gains in population health,
quality and productivity through
innovation and to address
variation in the system. The current
economic climate and our need to
plan for the next Comprehensive
Spending Review increase the
imperative for change.
HQCfA sets out ‘what’ we need to
do. The challenge is ‘how’ to do it.
History suggests that the process
of turning strategic goals into
implementation strategies that go
on to deliver real results for our
populations and patients is likely
to be the weakest link in the chain.
To achieve the breakthroughs we
seek in quality and efficiency, we
need to focus NHS change efforts
not just on new strategies and
working practices but on new ways
of thinking.
What’s the relevance of
organisational and system
health to this challenge?
One of the biggest shifts required
in our thinking, and part of the
‘radical transformation’ called
for, centres on how we think
about performance and how to
manage it. In recent years, we have
focused much of our performance
management effort on immediate
payoffs by achieving short-term
targets. However, evidence suggests
that this might be a risky strategy
longer term. It can stifle ambition,
and even incapacitate organisations
and systems like ours, leaving
them unable to achieve more than
specific deadlines or targets.
Across the globe, leading-edge
organisations and systems
are adopting a dual focus on
performance and the health of
the organisation and system.
Organisational and system health
is about having the properties and
qualities today that create the
conditions for high performance
tomorrow. Healthy organisations
typically have cultures which
promote trust, openness and
engagement and enable continuous
learning and improvement.
Everyone is pulling in the same
direction where it matters. There
is a ‘can do’ culture, supported
by effective working processes. A
healthy organisation or system can
absorb shocks and knocks from the
wider system it operates in and can
adapt in response to a changed
environment.
“Achieving this
vision of quality
requires a radical
transformation
across the entire
system. Change
on this scale, in a
system as large
and complex as
the NHS, has not
been achieved
before.”
— David Nicholson,
Annual Report 2009

|

70
Employees resistant
to change
Management behaviour
not supportive
of change
Inadequate resources
or budget
Other obstacles
39
33
14
14
% of efforts failing to
achieve target impact Factors contributing to failure
70%
due to
cultural
factors
Figure 1 - 70% of change programmes fail, and 70% of those that fail do so because
cultural barriers impede successful implementation
The evidence base on
transformational change suggests
that only one in three large
transformation programmes
is considered ‘successful’. Only
one in sixteen is considered to
be ‘extremely successful’. This
evidence shows that by focusing
on organisational health as well
as performance, we can create
the best conditions for change
in the NHS. The Five Frames, and
particularly the starting point of
a focus on organisational health,
force our attention to issues of
culture, mindsets and behaviour.
Evidence suggests that as many as
70% of change programmes that
fail do so because leaders don’t
address the cultural barriers that
impede successful implementation.
Successfully achieving this sort
of large scale transformation is
particularly challenging because
the NHS is a complex system,
made up of many different types
of organisations. For us, the health
of the entire system is as critical
as the health of the individual
organisations.

|
What’s the relevance of the
Five Frames to this, and how
do they fit with what we’ve
seen already?
In response to the challenges set
forth in High Quality Care for
All, David Nicholson consulted
experts within and outside the
NHS on how to achieve the type
of sustainable, large scale changes
that are clearly required. The Four
Principles are the result of this
initial consultation. They represent
the guidelines for how we should
work in the NHS called for in High
Quality Care for All.
The Five Frames provide a way to
realise this new way of working.
They are a powerful model
of change, representing five
important areas of consideration
for leaders in the NHS. Within
this model, a variety of existing
tools can be used. These include
tools such as Plan, Do, Study, Act
cycles, and Lean Improvement
methodologies. In addition, other
models for change are currently
used in the NHS, such as Vision-
Method-Expectation, which can
be used in tandem with some or
all of the frames. Finally, the NHS
Constitution, and in particular
the patient and staff pledges and
values within it, should provide
guidance for all change activities
considered.
What has the NHS
Management Board done?
The Board recognises that it must
embrace the change that has been
called for, and that any change
must start with itself. Rather than
telling others to change, the Board
is first changing its own mindsets
and behaviours. To this end, it has
been working through the Five
Frames to:
Identify the Board mindsets
and behaviours that impede
change, and consider the
mindsets needed for the
future;
Understand and define
the role it can play in
leading and supporting
large scale change;
Develop a plan of action
that reflects the new way
of working.
1.
2.
3.
The Four
Principles
of Change:
Co-production,
subsidiarity,
system alignment
and clinical
engagement.

|

What are they?
The Five Frames represent five
key areas of consideration for
any leader taking a team or
organisation on a journey
of cultural change.
The Five Frames are used when
designing and managing change,
but can also be an intervention
in themselves. Whilst the
ultimate result of using the Five
Frames should be a well-crafted
programme for change, the very act
of using them can be a powerful
catalyst for teams to change their
own behaviours.
The frames are the grounding
for a large-scale change strategy.
They do not represent most of the
work, which really starts to happen
towards the end of this process.
The Five Frames
The Five Frames
• Performance Health:
Change is not just about delivering performance today.
It is also about creating ‘healthy’ organisations and
systems which will deliver performance tomorrow
and the day after.
• The Discovery Process:
Creating deep, sustainable change is not just about
creating an excellent strategy or about redesigning
delivery systems and processes. It is also about changing
the mindsets which underlie behaviours and outcomes.
• The Influence Model:
When we plan actions to bring about the desired
changes in mindsets and behaviours in our organisations,
we need to make sure that we create a wide range of
initiatives that cover a broad perspective of change,
rather than concentrating on a small number of changes
that will not deliver wide scale change.
• Change Architecture:
In designing a change strategy, particularly in a complex
system, we need to plan carefully to make sure that the
initiatives are well-sequenced, occur at the right place
in the organisation, engage stakeholders and are well-
understood.
• The Benefits Hierarchy:
Measuring the success of change interventions is vital.
As well as ensuring that initiatives are on schedule
and milestones are met, and measuring performance
as the outcome, we need to measure organisational
and system health and make sure it is improving.
Frames
Current use
in the NHS
Evidence and
experience
Performance and Health Low
The Discovery Process Medium
The Inﬂuence Model Medium
Change Architecture Low
The Beneﬁts Hierarchy Minimal
Figure 2 - The Five Frames are currently at different levels
of development and exposure within the NHS

|
Building a Healthy NHS: Introducing the Five Frames
Central Manchester University Hospitals Foundation Trust
The Trust has recently embarked on
a large scale change programme, in
which the senior team is shifting a
strongly performance-driven focus more
towards a focus on quality, particularly
as it relates to patient experience, staff
engagement and patient safety.
The team recognised that the current
performance management systems
would not go far enough in winning
over ‘hearts and minds’ to the quality
improvements they aspire to.
In an attempt to address this, the team
was one of the first NHS Trusts to use
the Discovery Process, with its focus
on uncovering and ultimately shifting
underlying mindsets.A culture survey
was first undertaken by the team, which
identified various aspects of their culture
which they wanted to keep, others they
wanted to move away from and a new
set which they aspired to bring in.
After some preliminary work with
a facilitator from the NHS Institute,
Directors and Assistant Directors,
including Clinical and Finance Directors,
took part in two half-day workshops.
The two goals of the workshops were:
i) Explore the existing mindsets and
how these needed to change; ii) Look at
the existing Trust culture and determine
what would help and what would hinder
the success of the change programme.
An example ‘from’ mindset uncovered
was “Our workforce is large and
complex”, for which a new ‘to’ mindset
was agreed – “We value all of our staff,
everyone counts.”
On the back of the Discovery Process
work, the Quality strategy has
undergone several iterations.Workforce
engagement and participation is now
central to its delivery.The strategy has
only recently been launched, but the
team is confident that the strategy is
much more authentic and will have
greater impact and resonance as a result
of the mindset work they have done.
“The Discovery Process gave us
permission to think differently
about challenging issues and
behaviours, it allowed us to
come out of fixed mindsets.
Emotional intelligence matters.
It can result in real step
changes.”
— Helen Cameron,
Assistant Director of Nursing,
Central Manchester
NHS Foundation Trust
Why are they worth
considering?
The Five Frames are based upon
detailed evidence, drawn from a
broad range of studies from the
social sciences and business. The
frames can help improve the design
and leadership of your change
strategy in a number of ways:
They can help you find the
best changes to make in order
to deliver your strategy;
They provide structure and
support for you to have
conversations with clinical and
managerial leaders, improving
the alignment of your team;
1.
2.
They help identify where you
as a leader can be directly
influential, and where you
need to work through others;
They help make sure that your
organisation is solving the
right problems, by finding
the deeper drivers and barriers
to success;
They build momentum right
from the start, by visibly
having leaders work in
a new way together.
3.
4.
5.
“Using the
framework helped
depersonalise
and thus address
complex and
challenging
issues”
“The process
helped focus on
the value of the
culture changes
aspired to”

|

The process
involves paying
attention to getting
alignment and
getting leaders
walking the walk.
This can feel like
slowing things
down at first.
What it does,
however, is
radically increase
your chances
of success.
The field of organisational change
and the links between culture
and performance are areas where
empirical evidence has traditionally
been scarce. The Five Frames are
based on evidence where available
– some of this is laid out in the
appendix – though the evidence is
sometimes from the private sector.
We are committed to broadening
and deepening the evidence base
through the work that we do on
change within the NHS, and in
particular to making sure that the
empirical footing of our approaches
to change is increasingly sound.
How might the Five Frames
be used?
Ideally, you would want teams at
different levels in your system to
use the Five Frames in their own
way, identifying changes that are
right for their aspirations, but that
are aligned to organisational goals.
For instance, a Chief Executive
and senior team might identify
the changes which they want to
make and the initiatives which they
should sponsor to support change
throughout their organisation. At
the same time, the Chronic Disease
team might identify their own,
possibly different, changes which
they would like to make and a
corresponding set of actions or
initiatives. This would of course
be more time-consuming than
mandating changes from the
executive team. However, done
well, it would have the advantage
of using the journey through the
frames as a powerful catalyst for
change in itself.
Going through the approach
rigorously requires time. This
provides a great opportunity for
teams to explore and do real work
together, rather than transacting
regular business in the usual way.
The experience (the ‘how’) is as
important as the plans created
(the ‘what’).
National Leadership Leads
Team
“The Five Frames offer
a good structure and
process to think about
organisational culture
change. They present a
coherent package around
changing mindsets, and
this is what will really help
the NHS transform to make
quality our organising
principle. Developing a new
mindset and role-modelling
different leadership
behaviours will help us to
build healthy organisations.
The frames provide a new
rigour and approach to
complex transformational
change and tie in well with
the talent and leadership
planning process.”
— Caroline Wigley,
West Midlands SHA,
Leadership Leads Programme
Academy for Large Scale Change
The Academy for Large Scale Change
supports national and regional leaders
in the delivery of strategic, population-
level transformational change.
Approximately 70 senior leaders
from SHAs, DH and NHS Institute
for Innovation and Improvement are
members of the Academy.
In January 2009 the members were
introduced to the Five Frames and
recognised immediate synergies with
current change frameworks and the
Vision, Methods, Expectations model.
The Academy is mapping its thematic
programmes across the Five Frames.This
ensures that the work of the Academy
faculty is closely attuned with the
emerging Five Frames, identifying
opportunities for stronger integration
and co-ordination.

|
Is this a credible approach?
Yes – the Five Frames incorporate
valuable progress in the social
sciences over the past decade as
well as rich empirical evidence.
For example, there is clear evidence
that using the principles outlined in
the Change Architecture frame can
dramatically increase the chances of
a change strategy being successful.
Is this being used anywhere
outside the NHS Management
Board?
Yes – a significant number of
NHS organisations have used
different frames in the past two
to three years. Most of the current
application of the overall Five
Frames framework is at national
or regional level. For instance
a number of SHAs are taking their
leadership teams through the Five
Frames, and a number of regional
and national groups have now seen
the concepts and begun working
with them (e.g., the Academy for
Large-Scale Change, and the SHA
Leadership Leads). However, the
approach has application at all
levels of the health system.
How quickly should I expect
to see performance improve
as a result of my cultural
change strategy?
This depends on a variety of
factors such as the scale of your
organisation, the amount of
leadership attention you devote,
the resources you make available
to support it and how much
capability already exists in your
organisation for making change.
A specific team within an NHS
organisation, for example, might
see real improvements within
weeks. A small trust might see
improvements in their performance
in six months. For a larger, more
complex organisation or a system,
small improvements might only be
seen after a year or more.
Is there further support
available if my team and
I want to learn more?
Yes – the Institute wants to hear
back from you on the type of
support you would like. We want
to work with the chief executive
community and others to develop
the best support we can. We will
make further materials and support
activities available. Please email
annette.neath@institute.nhs.uk
with any queries or suggestions.
How do the Five Frames fit
with other change models
and approaches, such as the
Four Principles of Change?
The frames work best when
considered for your own context,
building on and adding to what
you are doing already.
For example, a PCT that
has embarked on a Lean
transformation strategy for
urgent care may use the frames
to think about the ‘health’ of the
urgent care system, the mindsets
that are creating variation in
the current system and the
dimensions of influence that are
needed to transform the system.
Or a Foundation Trust, which
has adopted the Vision, Method,
Expectations (VME) framework
(recommended as the leadership
for change approach in High
Quality Care for All), may find that
the frames are a powerful tool for
translating the VME model into
action.
The Four Principles of Change are
core to at least two of the frames.
The Four Principles should guide
what initiatives are planned, how
they are planned and who should
lead them.
Some questions about the Five Frames
The Five Frames
incorporate
valuable progress
in the social
sciences over
the past decade
as well as rich
empirical evidence.

|
10
Performance
Health
The
Discovery
Process
The
Influence
Model
Change
Architecture
Benefits
Hierarchy
Why is it
important?
Ensures the
‘change energy’
is focused on
what needs
improving. Can
provide ‘hard’
facts behind
‘soft’ issues.
Only by finding
and changing
the right
mindsets can
behaviours,
and thus
performance,
be changed
sustainably.
Creating this
balanced
approach,
which uses four
categories of
influence, will
dramatically
increase the
chances of
achieving lasting
change.
A programme
which is clearly
structured is
easier to run,
track and
communicate.
Any successful
change
programme
must maintain
buy-in and
energy.
By measuring
project
deliverables,
behavioural
changes
and health
outcomes,
where possible,
we can tweak
the change
programme as
we go.
What
is this
about?
Agreeing the
aspirations
for your
organisation.
Determining
what aspects
of your
organisation’s
health need to
be strengthened
to deliver this
aspiration.
Identifying
the desired
changes in
behaviour and
changes in
mindsets which
drive these
changes
in behaviour.
Generating
a set of self-
reinforcing
initiatives for
the change
process which
balance the
focus on the
individual with
a focus on
the working
environment.
Designing the
implementation
of the change
process so
that it is well
structured and
coherent, and
maintains the
energy required
for change past
the first few
months.
Finding and
implementing
the best metrics
to track the
success of the
change efforts
and using this
feedback to
constantly
readjust
implementation.
How do
we do it?
Variety of
strategic
documents as
inputs. Strategy
workshops, top
team interviews,
organisational
diagnostics,
focus groups.
A structured
process
involving
a series of
questions and
explorations
for the team.
Typically
requires a series
of workshops.
Use workshops
to brainstorm
and then
prioritise a set
of balanced
initiatives
around the four
categories of
influence.
Cluster the
initiatives into
major themes,
forming a
main message.
Prioritise
initiatives
according
to impact
and ease of
implementation.
Find the quick
wins.
Work your way
up the benefits
pyramid,
trying to find
solid metrics
as high up as
possible. Track
these during
implementation.
Quick reference
How does
this fit with
other NHS
methods,
tools and
initiatives?
HQCfA and
the NHS
Constitution
should be used
as inputs to
setting the
aspirations.
The Vision-
Method-
Expectations
framework is
complementary
to this frame.
NHS values
should be used
as a check
for proposed
changes.
Existing
initiatives can
be allocated to
one of the four
areas of the
Influence Model
– doing so will
reveal if there is
an approach too
favoured or a
‘blind spot’.
The Four
Principles of
Change are key
to architecting
a successful
change strategy.
Existing data
sources such as
the staff survey
for SHAs could
be used to track
performance.

11|
Performance
and Health
(The ‘And’)
A balanced focus on both
performance and health is
necessary for longer term
delivery. A thorough diagnosis of
organisational and system health
can help focus change efforts.
Too much focus on either
performance or organisational
health (the ability to deliver
performance in the future)
is problematic, though most
organisations tend to focus on
performance at the expense of
health. There is now compelling
empirical evidence from the
private sector showing a powerful
link between performance and
organisational health. This frame
seeks to address this balance, and
to ensure that any new focus on
health targets the aspects of health
which are most critical to delivering
against your aspirations.
The two big steps which might be
covered in this frame are:
Lay out the aspirations for
your organisation. This might
draw from a variety of areas
such as existing strategy and
vision documents, the
environmental context and the
preferences of the team. There
are some real choices to be
made here, as excelling at
everything is not possible.
1.
frame 1
Summaries of the Five Frames
Diagnose your organisation’s
health. A diagnostic might
include interviews, surveys,
focus groups and workshops.
Comparing the ideal health to
deliver the aspirations in step one
with the actual health uncovered in
step two should highlight current
gaps. These can provide the focus
for change and can act as inputs to
the Discovery Process.
A fact-base is useful, as there is
often a serious disconnect between
how healthy an executive team
believes its organisation is, and how
healthy the rest of the organisation
believes it is
There are of course many ways
to think about organisational
health, as well as a number of
tools available to help with the
diagnosis. The NHS Institute for
Innovation and Improvement has
commissioned a literature review
on different approaches and
frameworks for organisational
health. A framework and
corresponding diagnostic tool
developed by McKinsey Co.,
and now being used in some parts
of the NHS, is provided in the
appendix as an example of
one approach.
2.
Likelihood that business achieves above-median
ﬁnancial performance
%
31
48
68
2x
More than twice
as likely to
outperform peers
Organisational
health quartile
Bottom
Top
Middle
Figure 3 - In the private sector a strong link between performance and organisational
health has been established
Tips tricks
• Small, gradual changes
are less easy to make and
sustain than big ones!
Create an aspiration
around performance and
health, which is ambitious,
bold, and inspiring
• You always get more
of what you ask for!
In workshops use the
method of Appreciative
Inquiry to identify what
works well and leverage
pockets of strength in a
change strategy
• Health needs to be
understood at multiple
levels! The organisation
needs to be healthy, but
so too does the system in
which the organisation
exists, and any ‘tribes’
within the organisation

|
12
The
Discovery
Process
(The ‘Horseshoe’)
frame 2
The Discovery Process is a way
for leaders to dig below the
surface to identify deeper barriers
to and enablers of change at
a cultural level.
One challenge for cultural change
programmes is finding the most
critical factors that influence how
people work. The Discovery Process
is a tool which helps teams identify
a small number of critical changes
which should drive new outcomes.
The process starts with the team
considering the desired shifts
in outcomes they would like
to see. The team then works
its way around the Horseshoe,
systematically uncovering the
shifts in behaviours and mindsets
required to realise the ultimate
changes in outcomes.
The two big steps which might be
covered in this frame are:
Uncover the from–to’s:
This involves facilitating
a series of conversations,
which can be one-to-ones
or in groups, where you help
people to systematically lay
out what they see today
and what they want to see
tomorrow. Ideally, this
should be done following an
assessment of organisational
health (frame 1) so that the
mindsets reflect the changes
that the organisations need
to make.
1.
Probe for the enablers of
the from-to’s: This involves
probing to understand the
‘why’ that underlies the
current state and the future
states. Uncovering these will
inform your choice of
interventions, as well as
ensuring that you are solving
the right problem.
A significant side benefit of
this process is that it heightens
leaders’ own self-awareness and
commitment to change. This is an
example of how the Five Frames
approach can be viewed both
as a rigorous planning process
and a powerful change
intervention in itself.
The ‘Horseshoe’ illustrates both
the theory and the process itself
(see figure below). Mindsets
drive practices which in turn drive
outcomes. A fundamental change
in desired outcomes thus may
necessitate fundamental changes
in practices and thus mindsets.
2.
Tips tricks
• Probing for the root
causes of behaviour
is difficult and can be
uncomfortable! Use an
experienced, impartial
facilitator for the
workshops
• The most powerful change
themes often have their
origin in a dilemma! They
are about shifting from the
belief that you can either
do one thing or the other
to believing in being able
to do both at the same
time (e.g. reducing cost
and increasing patient
satisfaction)
“I’ll be seen as
dedicated if I go into
the office when I’m
obviously sneezing”
“I’m so busy…
I can’t take time off”
“I am valued for my
work, not for the
hours I work”
“The long-term is
more important than
the short-term”
Staff stay home when
they are infectious
Staff visibly praised
for judgement
IT set up well for
home working
Colds are contained
as much as possible
People come to
the office with
streaming colds
Outcomes
Practices
Mindsets
Outcomes
Practices
Mindsets
Current Desired
Colds are
spreading like
wildfire at work New strategic
direction
Culture change
Process
improvements
Figure 4 - A possible slice of the Discovery Process in healthcare

13|
The
Influence
Model
(The ‘Jigsaw’)
frame 3
In planning the set of initiatives
for your change strategy, it is
important to use a range of
influencing techniques, and not
just rely on a favourite approach.
You are much more likely to
achieve large scale change if you
plan a set of interventions that
complement each other.
The Influence Model, drawing on
the social sciences and extensive
empirical evidence, reflects the four
‘categories’ of influence which any
change process should address.
By designing a balanced set of
initiatives across the four influence
categories, the activities support
change directly and indirectly
via communications, training
and changes to the working
environment.
The four areas covered by the
influence model are:
Fostering understanding
and conviction
“…I know what is expected of
me, I agree with it, and it is
meaningful”
Reinforcing with formal
mechanisms
“…The structures, processes
and systems reinforce the
change in behaviour I am
being asked to make”
1.
2.
Developing talent and skills
“…I have the skills, capabilities
and opportunities to
behave in the new way”
Role-modelling
“…I see leaders, peers
and reports behaving
in the new way”
In many situations, there is over-
reliance on two or even only one
favoured area of the Influence
Model to try and bring about
change. Within the NHS reform
strategy, we have probably over-
relied on ‘formal mechanisms’ and
need to do more on the other three
areas of influence. Relying purely
on financial incentives, for example,
can often be less effective than a
more holistic change strategy – or
even counter-productive.
The creation of the ‘balanced’ set
of initiatives is typically achieved
via one or more workshops. When
this set of initiatives is agreed,
it can also be helpful to check
how each one maps to the four
categories of influence, arranging
the interventions around the jigsaw
(see the figure below for
an example).
3.
4.
Role-
modelling
Understand-
ing and
conviction
Skills
required
for change
Reinforcement
mechanisms
4
23 • Embrace regulators
more ﬁrmly as part of
the system
• Create and embed
SHA Assurance as a
developmental process
• Develop and deliver
quality strategy
• Communicate and
engage
• Embed the Four Principles
of Change in the centre
• Create greater
coherence of purpose
at the MB
Mobilise change agents
Create strong common
purpose amongst the
Top 1000
Nurture innovation and
best practice transfer
through appreciation
and celebration
Develop leadership
across the whole system
Find opportunities to
reduce cost
Organisational and
System Health Metrics
1
Figure 5 - How the NHS Management Board used the Influence Model
to design 12 initiatives that support change
Tips tricks
• Fear can only motivate
temporary change! For
change to be sustainable,
leaders must engage the
organisation with a vivid,
meaningful and exciting
vision of the future
• Relying on one part of
the Influence Model can
be counter-productive!
For example, top talent
will only perform to its full
potential in an organisation
with strong social networks
– without the supportive
environment, top talent
dramatically under-
performs
• Money is the most
expensive way to motivate
people! Non-financial
incentives can be not only
cheaper but also more
powerful than money

|
14
Change
Architecture
(The ‘Waves’)
Structuring the change strategy
around a small set of themes
will make implementation easier
and more successful. Sequencing
initiatives in order to generate
and then maintain the energy for
change is critical.
The Four Principles of Change in the
NHS (co-production, subsidiarity,
alignment and clinical engagement)
are particularly important when it
comes to creating the structure of
the change initiative. We call this
process the ‘Change Architecture’:
turning the list of agreed
interventions into a sequenced and
prioritised plan of activities.
This plays out in a number of ways:
1. Decide where in the organisation
the initiative should be led.
The principles of subsidiarity and
clinical engagement determine
that change should be led as
close to the front-line as possible
without sacrificing alignment of
the different aspects of change.
This has led, for example, to the
NHS Management Board asking
itself quite explicitly what are the
initiatives that we – and only we
– can lead.
2. Ensure coherence. Ensuring that
there is alignment and ample
opportunity for co-production
means using an easily understood
structure for organising and
communicating your change
process. Getting everything and
everyone aligned and pointing
in the desired direction is key
for purposeful change. See the
appendix for more on this.
3. Manage the change energy.
Sequence your initiatives so that
they generate sustained energy
for change, and so that they
maintain a sense of momentum.
Keeping the different
stakeholder groups energised is
vital for success, particularly as
the principles of co-production
and clinical engagement will
require high levels of energy
from large numbers of people
within the organisation.
One tool used for this is the
three waves. The implementation
of a comprehensive cultural
change programme can take
years. Therefore, implementation
should take place in waves. In
order to manage the change
energy, sequence initiatives based
on their potential for generating
and sustaining energy. Prioritise
initiatives around impact and ease
of implementation.
frame 4
Tips tricks
• Transformational
energy needs to be built
and managed continuously
to fuel the change! In order
to build it, focus on the
convincing and inspiring
delivery of a compelling
change story
• When it comes to
communication and
engagement: more is
more! Execute a number of
different communication
and engagement tactics
to build momentum and
energy for change
Premier mature
operator in the
region
Regaining stakeholder
conﬁdence
▪ Deliver short term cost
reduction promises
▪ Stabilise the production
decline
▪ Outline a credible
programme forward
Building towards
world class
▪ Develop true ‘front-line’
excellence
– Rebuilding operations
capability
– Develop world class
reservoir
management
– Superior project
delivery
Setting up for
sustainable future
▪ Fix critical delivery
processes
▪ Put lean and properly
resourced organisation in
place
▪ Rebuild the hydrocarbon
maturation funnel
▪ Drive down longer term
cost levels
Years 1 to 2 Years 2 to 3 Years 4 to 5
Declining
performance
and market
Figure 6 - Recent example of Change Architecture ‘waves’ used by
an international oil company

15|
The
Benefits
Hierarchy
(The ‘Pyramid’)
It is important to measure
changes to organisational and
system health as well as the usual
measures of performance and
project implementation.
Organisations are deeply complex
systems, with many hidden and
often contradictory aspects.
Initiatives which aim to influence
them can have unintended and
unpredictable consequences. As
such, it is important to watch
the progress of a cultural change
effort as closely as possible, and at
different ‘levels’ – the basic project
outcomes, the actual changes in
behaviour, performance outcomes
and overall vision.
By default, most organisations
going through a change process
will measure the progress of
implementation (e.g. milestones
and budget). They will also usually
measure their performance (e.g.
clinical outcomes), and in the case
of the NHS will also measure higher
level outcomes such as population
health outcomes. These measures
are influenced by so many factors
that it can be difficult to assess
the contribution of the change
initiative to those outcomes.
The Benefits Hierarchy reminds us
that there are some layers between
these two extremes – measuring
organisation and system health,
and its impact on performance (see
figure below). What this means in
practice is:
It is important during the
change process to measure
health, and to make sure that
the desired changes are
happening. This may mean in
practice regularly repeating
some of the diagnostic tools
such as surveys or interviews.
Understand the linkages
between organisational and
system health and
performance. As, for example,
collaboration improves in an
organisation it is important to
understand whether the
change is leading to a genuine
improvement in performance,
how and by how much.
Assumptions will have been
made during the diagnostic
and design phases, and these
need to be empirically tested
to ensure that the change
initiative remains on track.
1.
2.
frame 5
Programme metrics(e.g., initiatives
delivered on time and to budget)
Organisational and
system health
Public
health
outcomes
Performance (e.g.,
speciﬁc aspects of
patient care)
• Implementation
programmes are
commonly measured, as
are performance
outcomes
• What can be missed is
health metrics
• These will provide
valuable feedback on
what is and is not
working in your change
programme
Figure 7 - The Benefits Hierarchy – Measuring Outcomes at Multiple Levels

|
16
Appendix
This appendix
provides additional
detail on the
Five Frames.
It is not intended
to be complete
or exhaustive, but
rather to offer real-
life examples of
how the frames
have been used,
some of the
empirical evidence
underpinning them
and more detail on
tips and tricks for
their use.

17|
Performance
Health
(The ‘And’)
frame 1
Appendix Frame 1
tools
Diagnosing Health with the Organisational Health Index (OHI)
There are of course many ways to think about organisational health, as well as a number
of tools available to help with the diagnosis. McKinsey Co. has developed a model which
considers nine dimensions of health (see figure below).This framework is supported by
McKinsey Co.’s Organisational Health Index (OHI), a survey-based diagnostic tool.
These nine dimensions group to form three core themes:Alignment, Execution and Renewal.
Health in the various dimensions is correlated with different aspects of performance.
The OHI survey provides scores across the nine dimensions by examining thirty-four working
practices.An example with a PCT is provided below.
The nine dimensions are described below, as questions beginning with ‘How effective,
and in what ways does the organisation...’:
Direction: …articulate where the organisation is heading, how to get there, and align
people around the vision?
Coordination Control: …measure and evaluate performance and risk?
Innovation: …generate flow of ideas and change so that the organisation can
sustain itself, survive, and/or grow over time?
Motivation: …inspire and encourage employees to perform and to stay with
the organisation?
Environment Values: …shape the quality of employee interactions (e.g., culture,
workspace design) and foster a shared understanding of core values?
Capabilities: …ensure that the requisite internal skills and talent exist to support
the strategy and create competitive advantage?
External Orientation: …engage in constant two-way interactions with patients,
suppliers, partners, or other external groups to drive value?
Accountability: …design structure/reporting relationships and evaluate individual
performance to ensure that people are accountable and take responsibility for
performance?
Leadership: …ensure that leaders shape and inspire the actions of other
organisational members to drive better performance?
•
•
•
•
•
•
•
•
•
Figure 8 - Nine dimensions, three themes
Alignment
Are people at all levels
aligned around the
organisation’s vision,
strategy, culture,
and values?
Execution
How does the organisation
execute in accordance
with its strategy?
Can the organisation
perform essential tasks
with its current capabilities
and motivation level?
Renewal
How does the organisation
understand, interact,
respond, and adapt to
its situation and external
environment?
Cluster
Direction
Coordination
and control
Accountability
External
orientation
Innovation
Capability Motivation
Environment
and values
Leadership
Elements of organisational health

|
18
example
Application of OHI diagnostic in an NHS PCT
As part of its overall organisational development plans, a PCT conducted a deep
organisational diagnostic using McKinsey Co.’s Organisational Health Index.
The OHI was one tool the PCT used as part of a rigorous process to: i) Understand the
competencies and governance it required to fulfil the defined strategic priorities; ii) Analyse
its current capabilities and capacities; iii) Determine the priority areas and potential solutions
for its World Class Commissioning Development Plan.The OHI tool helped to identify
a range of strengths and gaps in the organisational health of the PCT relevant to its goals.
An implementation plan has now been developed to build on the strengths and address the
gaps identified to achieve each World Class Commissioning Development Plan objective.
55
59
56
52
29
2030 2
11 8 21 29 2
3
2
11
25
12 10 26
7
8
0
12
18 6
3
0
11
20 8
34
2
2
16 14 12
▪People in NHS ABC feel personally accountable
for the results they are expected to deliver
▪Leaders in NHS ABC consult with employees on
issues that affect them
▪Good performance is recognised and
rewarded in NHS ABC
▪Poor performance is identiﬁed and
acted upon in NHS ABC
▪Employees in NHS ABC feel trusted to do their
jobs well
67%
▪The responsibilities of my team/group are clear
to me and to others across NHS ABC
67%
62%
59%
31%
22%
Strongly agree Disagree
Agree Strongly disagree
Neutral
Not observed
Distribution of answers, %Survey questions
% agree or
strongly agree
Figure 10 - Survey details for one element of organisational health – Accountability
Average score
ABC PCT
Distinctive
Superior
Common
Not effective
Maximum PCT score
Average PCT score
Direction
Leadership
Environment
Values
Coordination
Control
Accountability
Capabilities
Motivation
External
Orientation
Innovation
% of respondents agreeing or strongly agreeing
NHS ABC’s
capabilities are
perceived as
signiﬁcantly
below average
NHS ABC’s
leadership is
perceived as
above average
NHS ABC’s
accountability is
perceived as
below average
0 10 20 30 40 50 60 70 80 90 100
Figure 9 - Overall, the application of the Organisational Health Index tool
shows a PCT which is in relatively good health
Based on the results of the OHI, the PCT has focused on three specific improvement areas:
Developing robust talent and performance management systems to identify and reward
good performance and provide developmental support where required.
Building capabilities, particularly where these are necessary to deliver against the
strategic plan and objectives.
Developing systems to build accountability, e.g. cross-directorate working teams.
•
•
•

19|
The link between Performance and Health
The insight behind this frame is that improving organisation and system health is as important
as performance.Too often, short-term performance is prioritised over long-term goals. But
ignoring organisational and system health typically damages future performance and makes it
difficult to adapt to new directions (e.g. HQCfA) or environments (e.g. economic downturns).
There is strong evidence for organisational health. The NHS Institute and Matrix Insight
will publish a review in June 2009, titled “Organisational health: a new perspective on
performance improvement?”, and to be available for download at www.institute.nhs.uk.
Many high-performing companies struggle to maintain their success over time – a study of
fifty-four high-performing companies showed that only 33% sustained performance twenty
years after the initial research took place (see figure).Warnings of deteriorating health
typically surfaced five to seven years before performance suffered. In health care, Ham et al
(2003) showed that in pilot projects for the National Booked Admissions programme,
only one-third continued changes after the 18-month pilot, and one-third failed to sustain
their improvements.
R2 = 0.54
-2.0
-1.8
-1.6
-1.4
-1.2
-1.0
-0.8
-0.6
-0.4
-0.2
0
Strength of OHI
Unit 2
Unit 1
Distance index (gap to industry best performance benchmark)
$ per unit produced
Small
StrongWeak
Large
Unit 3
Unit 8
Unit 4
Unit 5
Unit 11
Unit 12
Unit 13
Unit 15
Unit 9
Unit 10 Unit 16
Unit 7
Unit 14
Unit 6
Gap to
potential
Figure 12 - Organisational health has been linked to performance
on a business unit level
Where are they now? (2002)
High-
performers
Struggling
21%
46%
33%
Do not exist
Struggling
Still high
performers
43
18
54 companies
‘built to last‘*
(1982)
(1997) * 7 companies are common to both
Figure 11 - High-performing companies struggle to maintain their success over time
evidence
Performance and health have been quantitatively linked. Companies with top scores
on key health indicators are twice as likely to have above median financial performance
compared to unhealthy companies (see figure on page 11).The relationship between
performance and health also exists at the business unit level (see figure below).

|
20
If we dissect what we do right and apply the
lessons to what we do wrong, we can solve our
problems and energise the organisation at the
same time. What is more useful – to demoralise a
successful workforce by concentrating on their
failures or help them over their last few hurdles by
building a bridge with their successes? Don't get
me wrong, I am not advocating mindless happy
talk. We cannot ignore problems, but we just
need to approach them from the other side
– T. H. White, President GTE
Telephone Operations
When we were most successful,
what were we doing?
What does it look like when we are
at our best?
What possibilities exist that we have
not yet considered?
What is the smallest change that could
make the biggest impact?
I will be most proud of this corporation
in 2010 when...
Example questions
Figure 13 - Asking questions around the positive attributes of an organisation will
recognise strengths and enhance value
tipstricks
In McKinsey Co.’s framework and the related OHI tool, organisational health is driven
by the nine organisational dimensions, explained above, and thirty-four underlying
management practices. In creating the aspiration focus on improving a limited set
of practices crucial to your specific system. Identifying and targeting these will
deliver better results than spreading your effort across the whole broad set.
Small, gradual changes are less easy to make and sustain than big ones!
Radical, sweeping changes are often more successful, because they quickly show
results. Create an aspiration around performance and health which is ambitious,
bold, and inspiring.The aspiration should articulate a sustainable step-change
in performance and health and be anchored in the reality of today.
You always get more of what you ask for! Focusing on what doesn’t work is much
less powerful than focusing on what already works well. In workshops use the method
of Appreciative Inquiry to identify what works well and leverage pockets of strength
in the change strategy (see figure for example questions).
•
•
•
Employees will commit most to what they have understood, done and decided
themselves! Much of the energy invested in explaining the need for change would be
better spent on direct upfront involvement. Use the output of the fact-gathering to hold
up the ‘mirror’ in a workshop and involve as many key stakeholders as possible
in confronting the reality of today. Build ownership by letting them discover the need
for change themselves.
The organisation may not be homogeneous! ‘Identity group’ cultures (i.e. groups
within an organisation) have a more immediate effect on individual employee
behaviour, while organisational culture is key to aligning across groups.The two must
therefore co-exist and be shaped as mutually reinforcing. During the fact-gathering
phase, understand the balance between the groups’ cultures and the organisation’s
culture, and whether the organisational culture is strong enough to allow sufficient
coherence. Involve stakeholders from the most relevant groups early to gain ownership.
Think about system health as well as organisational health! The NHS is not
a single organisation, rather it is a system of organisations which interact. One
implication of this is that leaders of organisations also have a role as leaders within
the system, and so thinking about system health as well as organisational health
is important.
We are in the health business – for healthy organisations as well as people!
It is a powerful construct to apply the ‘health’ metaphor to our organisations and
systems as well as the populations and patients we serve.To achieve our goals, we
need the NHS system to be healthy – and the other groups and systems that it interacts
with to be healthy as well.We cannot ignore parts of the system. In a healthy system,
leadership styles must be based upon influence more than control.
•
•
•
•

21|
example
The Discovery Process of the Management Board
The NHS Management Board went through a facilitated Discovery Process, to identify desired
shifts in their own behaviours and mindsets. Below is a subset of the mindset from-to’s which
they agreed.This set provided the input to the Influence Model frame, as initiatives were
devised to support these shifts.
Appendix Frame 2
Value and
quality
We care about quality
but
our focus is on resources and
narrow quality metrics
We focus on cost, quality and value for money
and
do not think about one without the other, because every pound
wasted is someone’s lost opportunity
Working
together
We are proud of how we execute and what we achieve
and
recognise that we need to work in and learn from partnerships
within and outside the NHS to achieve more, for us, my team and
the whole system
We have individual accountability and
consequences
but
do not collaborate well within my
organisation and beyond
To . . .From . . .
We want to excel professionally
and
feel ownership for achieving world-class outcomes and standards
for the system
We have minimum standards
but
mediocrity is good enough
Excellence
We have a focus on delivery
but
only targets and fear make people deliver
Challenge
Support
We want to feel challenged and challenge others
and
be supported and support others in striving for ever
better outcomes
Innovation
We will be recognised for success
and
want to learn from failure as well as success in our restless
pursuit of change and improvement through innovation
We want to improve
but
innovation is risky and failure will be
punished
1
2
3
4
5
…
Figure 14 - Excerpt of outcomes of the Discovery Process
– NHS Management Board example
The
Discovery
Process
(The ‘Horseshoe’)
frame 2
Outcomes
Practices
Mindsets
Outcomes
Practices
Mindsets
Current DesiredExamples Examples
System biased towards cure as opposed to
prevention
Marginal expenditure and investment is not
always spent most effectively
Some conditions (e.g., dementia) receive
disproportionally little attention and few
resources
Budget allocation used to drive capacity building
and cost cutting, not clinical excellence
Mental health is not considered as important as
physical health in prevention, diagnosis and
treatment
Workforce not sufficiently reviewed for
effectiveness
More people are granted better and
faster access to the system
All patients have access to the best
available treatment and care
Care is provided in the most efficient and
convenient way to all patients
Funding is used to encourage clinical
excellence
Greater focus on prevention
Resource allocation must be based on
disease factors, clinical factors and
patient factors like experience and access
Quality and efficiency are closely
interlinked
Breakout groups populate the
lower bend of their Discovery
Process with ‘current’ and
‘desired’ mindsets
Pre-populated outcomes
and practices can be
amended and added to
workshop materials
Figure 15 - Sample output of a Discovery Process workshop with the NHS
The desired and current outcomes, behaviours and mindsets were populated in a fact-
gathering phase, drawing on HQCfA, interviews and workshops. Below is an example
of how the ‘Horseshoe’ is followed during a workshop.

|
22
There are of course many diagnostic tools available that can be used as inputs to the
Discovery Process. One of these is McKinsey Co.’s Culture Survey.This can be used to
highlight the key characteristics of a working culture which the team sees today and would
like to see in the future.The tool is described in more detail later on in the appendix.
The figure below gives an example output of the values survey used in one area of the NHS.
Top 10 current
Reactive
Accountability
Internal politics
Results-oriented
Task-oriented
Silos
Having a noble purpose
Operational focus
Acknowledge Keep Build
Top 10 desired
Values-driven
Making a difference
Being adaptable
Continuous
Improvement
Courage to do
what’s right
Quality focus
Excellence
Customer focus
Inspirational
Caring
Slow-moving
Bureaucracy
Inconsistent
Hierarchical
Figure 16 - Sample output of Culture Survey used in the NHS

23|
“We think, we already know
everything . . . there is nothing to
be gained from looking outside”
“It is not worth my job to
challenge the status quo”
“Mistakes are hidden and not
used as an opportunity to learn”
“If it’s not broke, don’t fix it”
“Innovation is risky”
▪ Lack of motivation: Employees perceive there
are no rewards for pushing the boundaries
▪ Arrogance: Leaders and employees believe that
they are the best
▪ Lack of respect: Leaders do not believe that
employees have anything to contribute
▪ Fear: Employees fear the consequences of
challenging their leaders
▪ Blame: Employees believe people are quick to
blame if a new idea goes wrong
Typical underlying mindsetsExample symptoms
Figure 17 - Stifling innovation - Example symptoms and typical underlying mindsets
from banking industry
Typical mindset changes that enhance innovation
Across organisations, evidence shows that there are a number of typical mindsets that stifle
innovation and entrepreneurship. Identifying and shifting those beliefs is key to enhancing
innovative organisational capabilities – without changing them, process redesign is less
successful.The examples given below show how the process worked for an organisation
in the banking industry.The first figure shows how some symptoms are linked to a set of
underlying mindsets. It is these mindsets which ultimately need to be addressed.The second
figure shows the shifts in mindsets which the team identified as desirable.
“Probing my client about its financial
situation is prying into its private
affairs”
FROM: Transactional TO: Relational
“I am responsible for addressing their
articulated and unarticulated needs”
“Understanding my clients’ full
situation is the only way I can
appropriately advise them”
“My success depends on optimising
my area”
“I view other areas as a hindrance –
‘they’ are incompetent and selfish”
FROM: Silos TO: Collaboration
“My success depends on helping
optimise the company result”
“There is no ‘they’ – I assume
competence and goodwill in
other areas”
“The problems we face are beyond
my control“
“I show up at every meeting so I can
watch my back”
FROM: Blame TO: Accountability
“If I’m not part of the solution, I’m
part of the problem”
“I trust others to do what they are
supposed to do in a fair manner”
Figure 18 - Typical examples of mindset shifts necessary to enhance innovation
from banking industry
example

|
24
Impact of mindset and behaviour transformations
Identifying crucial mindset shifts is one vital step in the journey towards increasing health.
Transforming those mindsets and, with them, the behaviours that drive performance comes
next.A wide range of successful programmes give evidence that underlying beliefs can be
effectively changed over time.The exhibit below shows an example of a bank which wanted
to make quality its core focus.
1Cost reduction
Quality focus
Cost reduction Cost reduction Cost reduction Quality focus11 1 1
Shareholder value Profit Shareholder
value
Quality focus Cost reduction2 2 2 2 2
Results
orientation
Shareholder value Accountability Shareholder value Accountability3 3 3 3 3
Profit Results
orientation
Quality focus Accountability Continuous
improvement
4 4 4 4 4
Goals orientation Profit Continuous
improvement
Achievement5 5 5 5 5
Bureaucracy Continuous
improvement
Results orientation Profit Profit6 6 6 6 6
Hierarchical Quality focus Continuous
improvement
Results orientation Results orientation7 7 7 7 7
Short-term focus Bureaucracy Achievement Achievement Community
involvement
8 8 8 8 8
Control Achievement Bureaucracy Community
involvement
Shareholder value9 9 9 9 9
Risk averse Goals orientation Being the best Customer
satisfaction
Customer
satisfaction
10 10 10 10 10
28
Accountability
Year 0 Year 1 Year 2 Year 3 Year 4
Figure 19 - Example – In annual surveys about their company’s values, employees
of a major bank ranked quality higher each year
evidence
“I will change my
approach to work
and to the benefit
of the company.
Don’t let it fade
out”
“Best personal
development
programme
I’ve been on. A
powerful change
agent programme
for the company
– from culture will
flow value”
“An enlightening
experience with a
profound impact
on the way I see
myself and the
way others see
me. With the
commitment
which I already
sense, the
workshop will
create a visible
shift in the
company’s culture
and values”
“A very good
programme.
It has the potential
to truly help
transform the
company, and
we’re clearly
seeing the impact
already”
Example quotes from a mindset and behaviour transformation

25|
tools
What a Discovery Process workshop can look like
A Discovery Process workshop uses input from the fact-gathering phase to start and focus
the discussion. Surveys and/or interviews are valuable sources of insight into the current
‘reality’ of the organisation or system.
One tool that can help with the diagnostic is McKinsey Co.’s Culture Survey. It allows you
to identify the key characteristics of the current culture which the team see today, and those
they aspire to for the future.The team can then examine the extent to which they overlap. In
an internet or paper survey on perceptions of the company’s culture, participants pick 5-10
words from a list that most or least describe their personal values, as well as their current and
desired organisational experience.An example output can be found earlier in this section.
During the workshop, work in breakout groups around specific categories of practices
or outcomes, then discuss findings (see figure for an example agenda of a Discovery
Process workshop).
Time Topic Description
09.45-10.10 Introduction to the Day ▪ Introduction to the day
10.25-11.15 The Discovery Process
breakouts
(Breakouts – facilitated)
▪ 4 mixed groups of staff from different levels
▪ Each breakout around a single topic, e.g., clinical procedures,
capabilities, resources, innovation
▪ Examples of outcomes and practices provided for each topic
▪ Single example of a mindset (from – to) provided for each topic
▪ Outputs
– Edited poster with outcomes and practices
– Poster with current and desired mindsets on post-it notes
11.15-11.30 Feedback ▪ Short presentation by each breakout group of the current and
desired mindsets
10.10-10.25 The Discovery Process ▪ Introduction to the detail of the Discovery Process, including a simple
example of the process
11.40-11.55 Prioritisation session
(Presentation and
Gallery walk)
▪ Introduction to mindset grouping by facilitator
▪ Each participant is then given stickers to stick onto the mindset
groups that provide the greatest opportunities for raising quality in
the system
12.25-12.30 Wrap up and next steps ▪ Thanks for useful input
▪ Outline of next steps
11.55-12.25 Feedback ▪ Summary and synthesis by facilitator of which mindset groups
provide the greatest opportunity for raising quality
▪ Pair-share discussion on initiatives that could facilitate these mindset
changes
10 minute tea break
Figure 20 - Example agenda for a Discovery Process workshop

|
26
tipstricks
Probing for the root causes of behaviour is difficult and can be uncomfortable!
Use an experienced, impartial facilitator for the workshops.
The most powerful change themes often have their origin in a dilemma!
They are about shifting from the belief that you can either do one thing or the other
to believing in being able to do both at the same time (e.g. reducing cost and
increasing patient satisfaction). In probing the root causes of behaviour pay special
attention to potential dilemmas. Question existing beliefs on relationships between
behaviours and mindsets.
Identify mixed blessings! Some common practices typical for your system might
simultaneously have good and bad effects on your strategic objectives. For example,
healthy competition can be a useful impetus, but taken too far it can hamper
collaboration. Identify those ambivalent practices and drill down to the mindsets driving
them. On the mindset level there will often be a possibility to reap more of the benefit
while avoiding the downside.
•
•
•

example
Maternity service in an NHS hospital
A maternity service in an NHS hospital was found to under-perform compared with other
maternity services in different organisations, as well as to other services within the trust.
The Influence Model was used to devise a balanced set of actions that addressed this.
The highest potential actions were then piloted, followed by roll-out of those that worked.
One year later, performance measures have improved significantly (e.g. satisfaction of the
women who use the service has gone up by more than 50%). Below are the actions around
the Influence Model, together with detail on some of the successful actions.
During the idea generation phase the Influence Model was used to determine a balanced
set of co-ordinated interventions, covering all four elements required to embed change
(see figures).
27|
Building a Healthy NHS: Introducing the Five Frames
Appendix Frame 3
Agreed standards of behaviour
for all
Increased senior doctors’
Presence on labour ward
• Created a list of standards, based
on ‘Putting Patients First’ guidelines
• These show the behaviours that everyone
will display (no matter
how senior)
• Senior doctors located in clinical areas,
or in adjacent on call office when on-
service
• Senior doctor personally leads rounds
and daily quality meeting
Daily quality meeting
Improved doctor/midwife
communication
• Introduce a daily, multi-disciplinary quality
meeting at shift handover
• Six item satisfaction questionnaire used
with all mothers
• Scores displayed and discussed at daily
quality meeting
Whiteboard show-
ing survey results
• Were you treated with
• kindness and respect?
• Was the information provided
• during labour appropriate to
your needs?
• Did staff respect your privacy
• and dignity?
• …
Six questions
Figure 22 - Examples of some key interventions in an NHS maternity service
Interventions
Fostering understanding and conviction
“I understand why continuous learning is important
for our organisation and what my role is in it”
Role modelling
“I see superiors, peers and subordinates behaving in
a way that encourages learning”
Developing talent and skills
“I am supported in continuously developing the skills
and capabilities I need
Reinforcing with formal mechanisms
“The structures, processes, and systems reinforce
continuous learning”
Widely engaged staff about what ‘great’ would
look like
Agreed a shared vision of what the service should
look like
Based on this vision, created a performance
scorecard
Created standards of behaviour for all
Increased presence of senior clinicians in clinical
areas
Introduced joint ward rounds for midwives and
doctors
Trained staff on:
Interpersonal styles and team effectiveness
Running workshops
Giving and receiving feedback
Building the change story
Instituted daily quality meeting, led by senior
doctors
Used visual management board to present data,
updated daily
Clarified midwifery management structure to
ensure clear role definition and reporting lines
Reduced time spent by clinical staff on non-
clinical activities
Figure 21 - Interventions were designed on four levers reflected in the Influence Model
“I feel like I’m
working in a new
hospital!”
– Midwife
“Vastly improved
from when I had
my son here
two years ago”– Mother
“For the first time
I understand what
the world looks
like through a
mother’s eyes
– and a midwife’s”
– Senior Doctor
The
Influence
Model
(The ‘Jigsaw’)
frame 3

|
28
Building organisational health in banking using
the Influence Model
A majorAustralian bank,ANZ, has undertaken a comprehensive change programme targeted
at building organisational health that has led to a step change in terms of performance.
A fact base and a common vocabulary were established up-front using culture surveys,
deep structure interviews and focus groups.The root causes of current business challenges
were determined and a set of a few critical mindset shifts was agreed on.
Actions were defined around the Influence Model to create a balanced set of changes
to the employee environment, which promoted new behaviours.The figure below shows
the set of actions agreed for each influence category.
“Three and
a half years
ago, ANZ Bank
was the worst
performer of the
big four banks...
the transformation
has turned ANZ
Bank from a lame
duck into a highly
polished, money-
making machine.”
— Business Editor,
Australian Financial Review
•Created a transforming top team always
one step ahead of the broad effort (via
coaching, 360s, facilitation, team charter)
•Invested heavily in the top 100-300 leaders
as role models
•Identiﬁed and cultivated ‘change
champions’ from all levels in both formal
and informal leadership roles
Role-modelling
•Adjusted formal skill-building programmes
to incorporate culture overlay and build
needed skills (e.g. relational sales, giving
feedback with compassion)
•Adjusted on-the-job development activities
to include desired shifts (e.g. development
plans, self-guided learning)
•Adjusted hiring and promotion practices
to reﬂect desired culture
•Created a meaning-laden integrated
change story (setting cultural aims in the
context of the broad transformation)
•Cascaded the story into the organisation
in a personally meaningful way (writing
their own stump speeches)
•Complemented existing communications
efforts with ‘break the mold’ approaches
such as ‘viral’ communications
•Hardwired desired mindset and behaviours
into performance management, moving to
more balanced scorecard approach linked
to compensation
•Published quarterly performance for every
business unit publicly both internally and
externally
•Instigated ‘silly rule button’ to cut through
poor processes
Fostering understanding and conviction
Developing talent and skills Reinforcing with formal mechanisms
Figure 23 - Overview of initiatives addressing culture change
example

29|
4 1
23
Leadership actions
Opinion shapers
Interactions
Story development
(includes all the key
elements, e.g., values,
strategy, case for
change)
Story delivery (across
relevant levels, i.e.,
organisational,
employee, functional)
Organisation structure
Targets and metrics
Management
processes
Business processes
Rewards, recognition
and consequences
Information systems
Talent management
Hiring
Replacing
Retaining
Learning
On-the-job
development
Training
Action learning
Lever categoriesLever categories
Role-modelling
Fostering
understanding
and conviction
Developing talent
and skills
Reinforcing with
formal mechanisms
“…I see leaders, peers
and reports behaving in
the new way“
“…I know what
is expected of
me, I agree with
it, and it is
meaningful“
“…I have the skills,
capabilities and
opportunities to
behave in the
new way”
“…The structures,
processes and systems
reinforce the change in
behaviour I am being
asked to make“
Figure 24 - The Influence Model and lever categories
tools
Defining a balanced set of initiatives
In order to create a well-balanced change strategy, brainstorm initiatives across all four
categories of the Influence Model, and make sure you don’t have a ‘blind spot’ or an overused
quadrant.The figures below are meant to provide some thought starters on the types of actions
for each category, including more detail on the ‘Role Modelling’ category.
InteractionsInteractions
Improve quality of direction, interaction and renewal
– Identify and agree on team roles and priorities
– Spend time analysing the root causes of problems
– Provide coaching to individual members
Understand current degree of alignment around corporate
story/change agenda
Increase visibility of leaders through regular staff interaction
Create forums for leaders to interact with the rest of the
organisation
Use symbolic language and actions to emphasise importance of
the desired change to patients and staff
Identify inﬂuential stakeholders from all levels of the
organisation
Understand reasons for resistance
Change team composition to include key opinion leaders in
change processes
Ensure top management ownership of change through linkage
of programme success to their evaluation and rewards
Task change agents to carry the message to their environs
Description
Enlisting the support and
involvement of inﬂuential
stakeholders at all levels of
the organisation to assist in
shaping the desired
behaviors
Opinion
shapers
Opinion
shapers
Ensuring that group
dynamics are effective in
pivotal performance groups
Setting an example of
exemplary behaviour in day-
to-day interactions with
subordinates and patients
Leadership
actions
Leadership
actions
Example actions
Figure 25 - Example actions – Role modelling

|
30
Testing for ‘Goodness of fit’
Leadership
External orientation
Direction
Accountability
Environment and values
Capability
Innovation
Influence Model initiatives
Profile
elements
Coordination and control
Motivation
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
1. Consistency: Ensure alignment
of actions among performance
model elements
2. Complementarity: Ensure
integrated actions are taken across
all 4 influence model quadrants
3. Comprehensiveness: Ensure
sufficient actions are taken across
performance profile and influence
model to achieve desired outcome
but taking care not to overwhelm
the organisation with too many
actions
4. Context: Ensure actions are
aligned with the organisation's
strategic objectives and context
‘Goodness of Fit’ is the extent to which the
complete set of initiatives are consistent,
complementary, comprehensive, and
context-specific
Figure 26 - Testing for ‘Goodness of fit’
When you prioritise the initiatives and design the change architecture, revisit the Influence
Model to test the overall ‘goodness of fit’ of the change process.The set of initiatives should
ideally be consistent, complementary, comprehensive, and context-specific.

31|
Description
Acquired knowledge,
skills, and capabilities
that enable individuals
to act in new ways
Human
capital
Social
capital
Knowledge, skills, and
resources available in
and through the
personal and
professional networks
of employees
Business impact on . . .
Innovation
Employee
turnover
“We made lots of effort to
train the commercial bankers,
then as soon as we promoted
them, our competitors would
offer them a role”
– HR director,
financial services, Europe
“We trained someone and
then lost him to a hedge
fund in New York”
– Senior manager,
financial services, NA
(0.47)* (-0.41)*
(0.20)* (0.29)*
Illustrative interview quotes
* Denotes a statistically significant relationship
Figure 27 - Investing in human capital alone, without a dual focus on creating
social capital, can actually increase employee turnover
tipstricks
Fear or stress can only motivate temporary change! For change to be
sustainable, leaders must engage the organisation with a vivid, meaningful
and exciting vision of the future! To foster understanding and conviction, engage
staff with a meaningful story that combines positive, supporting messages with hard
facts that stress the need for action.
Working on just one corner of the Influence Model can be less effective
or even counter-productive! For example, investment in human capital without
also developing a supportive infrastructure increases employee turnover, as it builds
confidence and skills without enhancing employee commitment.Therefore, investing in
talent and skills – one category of the Influence Model – is not enough. In addition to
building individual capabilities, also invest in social capital in order to strengthen the
bonds between employees – the glue that holds the organisation together (see figure).
One survey of 50,000 employees, at 59 organisations worldwide, found that people
with lower social engagement were four times more likely to leave their jobs. Plus, each
time we avoid a member of staff leaving, we save £15,000 in new staff orientation and
lower productivity, as well as the effect on morale for remaining staff.
•
•

|
32
56% of transformations
that set good targets
succeeded, while 88% of
those who set badly
defined targets failed
% of respondents
Total respondents = 2,694
The targets were well defined in financial
or operational terms and represented a
genuine new level of performance
The targets were well defined in
financial or operational terms but
did not stretch the company
significantly
The targets were not well defined
Which of the following statements best describes the targets
your company set to define success for the transformation?
1046422
324694
2
7414 10
Extremely successful
Very successful
Somewhat successful
Not successful at all
Degree of transformation success
Figure 28 - Invest in setting clear, stretch targets – nine out of ten transformations
with ill-defined targets fail
Money is the most expensive way to motivate people!
Non-financial incentives can be not only cheaper but also more powerful than money.
In some cases expected financial incentives can even undermine intrinsic motivation.
Whenever possible use social rewards (compliments and praise) and positive feedback
to enhance motivation. From time to time employ small, unexpected rewards to show
appreciation and boost change motivation.
Employees need to be connected with a sense of purpose to motivate their full
effort and engagement. Such a sense of purpose is most powerful when it is rooted
in the organisation’s heritage as well as clearly consistent with its strategy.To engage
employees, ensure that the story is driven by a clear and persuasive rationale that
takes into account the organisation’s heritage and strategy as well as their individual
motivations.Also, understand why certain strategic directions are more or less available
dependent upon legacy and proceed from there.
Well-defined stretch targets are key to a programme’s success!
Setting challenging and specific goals with the opportunity for feedback greatly
improves employee performance. Reinforce with formal mechanisms: invest up-front
in definition of targets in clear financial or operational terms that represent a genuine
new level of performance (see figure).
Build some ‘quick wins’ into your change process! Quick wins build momentum
and energy as the perception of success is created and stakeholders get engaged.They
can also provide ‘air cover’ by demonstrating results while you plan more complex
aspects of the change process.
•
•
•
•

33|
tools
Creating the Change Architecture
In order to ensure that the change initiative is well understood, the transformation leader
– typically the CEO – and the core team need to design a three-level structure that links
initiatives and themes to the change story, and to assign accountability for elements
on all levels.
Appendix Frame 4
Estimated costs/impact Buy-in/ownership Recommendation
Potential staff
resistance
Role modeling
[E.g. Champions]
Formal mechanisms
[E.g., Process changes]
Cost
X GPB/quarter
Wave 1
Impact
[E.g., increase quality]
Initiative factsheet: [Initiative name]
[What does success look like]
Risk
High
Medium
Low
Risk
High
Medium
Low
Ownership
Initiative Leader:
xxx
Initiative team
ownership
Initiative and aspirations Outputs/coverage of organisation
Measures and targets
Understanding
[E.g. Workshops]
Skills and talent
[E.g, Non-mg skills]
[E.g., Patient satisfaction
From To
X% (2008) Y% (2009)]
[E.g,
potential staff
resistance]
Figure 30 - Factsheet for planning change initiatives
L2: Change themes
L1: Overall change story
L3: Initiatives
Figure 29 - The use of a three-level structure grouping the initiatives into change
themes and linking them to the story helps ensure coherence
Change
Architecture
(The ‘Waves’)
frame 4
Owners of initiatives should then scope and plan their respective initiatives. (An example
is below.) Doing so in a decentralised fashion will build buy-in throughout the organisation.
However, those plans must be relayed back to the senior leadership so that initiatives can be
prioritised and sequenced.A programme management office or change team is an important
consideration at this point to support initiative owners with tools and guidance for their tasks,
to collect results, and to manage the overall sequencing.

|
34
Application of three-level structure in performance
transformation
The three-level structure linking the individual initiatives through change themes to the overall
change story is a standard tool taken from performance transformation work.
The example given here is taken from the transformational journey of a basic materials
manufacturer aiming for a step change in terms of customer focus and operational excellence.
Vision, core themes and initiatives in this example reflect the three levels (L1-L3) of a coherent
transformation programme (see figure). In this case, the initiatives have first been piloted in
two business units and subsequently rolled out in waves across the organisation.
example
Eight Initiatives (L3)
• “By 2010, we will
become the reference
X maker. We will
capture present and
future client needs
better than any
competitor.”
• “We will operate
optimally to fulﬁll
these needs, and
develop an
incomparable pool
of talent to make this
happen.”
One Vision (L1) Three Core Themes (L2)
Building a unique
talent development
platform
Developing a
leading production
system
Fostering
commercial
excellence
Develop the long-term commercial
strategy
Align mindsets and capabilities,
processes, systems to execute
Determine long-term optimal industrial
conﬁguration
Increase the reliability of production
facilities
Accelerate the cost reduction
Determine the optimal way of organising
support services
Develop an integrated performance
management system
Develop an attractive and coherent
people development and performance
rewarding system
Figure 31 - Example – Performance transformation of a basic materials manufacturer:
one aspiration, three core themes and eight initiatives

35|
0
1
2
3
4
5
6
Extremely
Average
number of
tactics
used to
mobilise
staff
Extent to which transformation
was successful
% of respondents
Total respondents = 2,694
VerySomewhatNot at all
Using tactics to mobilise staff
Companies that used more
mobilising tactics, such as
creating a compelling
change story, were more
likely to be successful
Figure 31 - Investing in a set of different tactics to mobilise staff pays off
tipstricks
Transformational energy needs to be built and managed continuously to
fuel the change! In order to build it, focus on the convincing and inspiring delivery
of a compelling change story and on the behaviour of the leaders.
When it comes to communication and engagement, more is more!
Organisations that use more mobilising tactics are more likely to be successful
(see figure). Execute a number of different communication and engagement tactics
to build momentum and energy for change.
Frame the change in ways that connect with the values and life experiences
of the workforce! Do not assume that one message will reach every group of
stakeholders you need to get on board.The message to senior clinicians must be
framed very differently than the message to leaders of the finance function.
•
•
•
The amount of detail given on
the individual frames reflects their
level of development and exposure
within the NHS. As the Benefits
Hierarchy is still an evolving
concept no additional detail
is given on this frame.

|
36
nextsteps
So what can you do now?
Now that you have the context for the scale of change required across the NHS,
we would like you to have a conversation with your team about the implications,
opportunities and challenges for the part of the system you and your team lead.
As part of this, your team might consider:
What types of changes to how people work might be required, both in your
team and in your organisation and/or part of the system to deliver HQCfA;
How ready your organisation is to deliver the required changes;
How likely you are to succeed in achieving the required change, based on current
activities or programmes.
If you think all or some of the Five Frames introduced here may be of use to your
team, you can contact the NHS Institute for more information. (Email Annette Neath at
annette.neath@institute.nhs.uk.)
•
•
•

Inspiring change in the NHS: the five frames

Inspiring change in the NHS: the five frames

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