Lessons from Global Health Development: Harnessing Methods of Change
By Rob Thames
This is Part 3A of this three-part series.
This Part 3A briefly reviews four change methods and Part 3B will compare them.
“I have no idea how to change anyone. But I carry around a long list of people in case I ever figure out how.” - Anonymous
Eliminate four billion dollars of waste from a large healthcare system next year. Increase the CMS TPS (Total Performance Score) for a hospital from the national average of 38.1 to 60 in two years. Reduce maternal, child and infant mortality in Nigeria by 50% in three years. These are large-scale improvement goals – at healthcare system, hospital and population health levels, respectively.
Improvement at the community, organization and individual levels are all connected: improvement requires change and all change is personal. An organization is a group of people with a common purpose; and a community is a group of people with the potential for acting together (Taylor). While communities and organizations are made up of individuals, how they evolve and change is not merely an additive process of how each individual changes. Societies and organizations are complex adapting systems and their advancement matures through their disciplined movement.
Because social change is, first and foremost, behavior change, healthcare leaders and global health developers are, first and foremost, behavior change practitioners. Change practitioners realize that creating broader impact involves growing bundles of human energy whether they are individuals, organizations or communities. Change practitioners are flooded with a tsunami of advice: a recent Google search revealed nearly 10 billion results on how to change; a search on sustainable change produced over one-third of a million results. To cut through the overwhelming morass, four recognized and well-regarded methods are discussed and compared.
The four methods, MI, Kotter’s 8-Step Model, Baldrige Communities of Excellence, and SEED-SCALE, were selected to reflect and reveal the wisdom of a range of disciplines, purposes and evidence to aid change practitioners in the thinking and doing of their craft. A brief refresher is below.
Individual Level: Motivational Interviewing (MI)
The Motivational Interviewing (MI) approach to individual behavior change has its roots in psychological counseling (clinical psychologists Miller and Rollnick first published on MI in 1983) for addiction and coaches and health and fitness professionals use MI to aid their clients. The “spirit of MI” involves a partnership between client and coach/counselor that respects that the choice to change is owned by the client. In this collaborative process of Engaging, Focusing, Evoking and Planning, active and reflective listening are key to encourage and support client “change talk” (vs sustain talk). A critical element is evoking from the client reasons for making the change using O.A.R.S. (Open-ended questions, Affirmations, Reflective listening and Summarizing) to address ambivalence, readiness and harness the power of “why” the client wants to change. As Miller notes, “People are the undisputed experts on themselves. No one has been with them longer, or knows them better than they do themselves. In MI, the helper is a companion who typically does less than half of the talking.”
Organizational Level: Kotter’s 8 Steps
The 8-step large-scale organizational change model developed by Harvard Professor and business author Michael Kotter intends to increase an organization’s chances of successful change by avoiding failure. This model advocates initiation of movement by creating a sense of urgency, forming a powerful guiding coalition, and developing and communicating a vision. To build and maintain momentum, it prescribes empowering others to act on the vision, creating short-term wins, consolidating improvements, and hard-wiring the changes. Designed for application by management to an organization, it is grounded in organizational change management theory. According to Kotter, “What leaders really do is prepare organizations for change and help them cope as they struggle through it.”
Community Level: Baldrige Communities of Excellence (COE)
Named after Malcolm Baldrige, Secretary of Commerce from 1980-87, the Baldrige framework was developed by the National Institute of Standards and Technology (NIST) for self-application by companies in any industry to pursue excellence. The framework is based on core values and concepts that represent beliefs and behaviors found in high performing organizations. General areas for evaluation include Leadership, Strategy, Customers, Measurement/Analysis, Workforce, Operations and Results. Organizations in six industries, including four in Business and Non-profit, Healthcare and Education are eligible to apply for the annual Malcom Baldrige National Quality Award. Recently, a seventh category was added for use by communities: “Communities of Excellence.” Interested organizations, and now communities, may utilize the framework or engage trained external surveyors/examiners to conduct an assessment of the organization or community according to identified criteria.
Population Level: SEED SCALE
The SEED-SCALE model was developed by global health development and social change practitioners and researchers Carl Taylor (1916-2009), founder of Johns Hopkins International Health School of Public Health, and his son Daniel Taylor, Founder and President of Future Generations, a community-based conservation and development organization and graduate school. They found that sustainable social change in communities and populations emerges from an iterative process based of four principles: build from local strengths (vs solely need-based), use a three-way partnership (bottom up, top down, and outside-in), focus on behavior change (vs only measuring outcomes), and base decisions on evidence and data (vs power, populism, politics, etc.). Self Evaluation for Effective Decision-making involves three progressive SCALE (Systems for Communities to Adapt Learning and Expand) dimensions. SEED-SCALE is a process to improve communities and lives that are available to all, improve quality with growth and assert “act global, think local.” “When human energy is viewed as the essential commodity that will improve lives, individuals are shown to already possess an infinite resource they can build on. Therefore, resourcefulness is the end result, rather than a compulsion for resource consumption.” (SEED-SCALE website).
Each of these approaches to change have strong followings, different strengths and applications. How can the best of all of them be leveraged to help you affect sustainable change? Part 3B of this series will compare and draw insights from these four methods to help strengthen your approach to change.