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Understanding how to motivate change requires more than getting your team to do what you want them to do.
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Psychology Eats Improvement for Breakfast

By Shobhan Thakore | Thursday, April 11, 2019

Business management expert Peter Drucker famously said, “Culture eats strategy for breakfast.” He meant that all attempts at change are likely to fail without an enabling organizational culture in place. It stands to reason that without addressing people’s psychology toward change, all attempts to influence culture will likewise fail.

So, how can we help improvers appreciate this and equip them with the right skills so psychology doesn’t eat improvement for breakfast? 

The Most Frequently Asked Question

I am the current lead for the Scottish Quality and Safety Fellowship (SQSF). SQSF is an improvement science training program for clinicians with participants from a range of countries, including Scotland, Northern Ireland, the Republic of Ireland, Denmark, Norway, Canada, and Wales. Having been an SQSF Fellow a few years ago, I can attest that the fellowship is a fantastic opportunity to learn the skills of quality improvement and the key elements necessary to deliver safe patient care.

The fellows learn how to use improvement tools, such as pareto charts, process maps, and control charts. However, the most common question I am asked is not “How do I draw a run chart?” Instead, it’s “How do I get my team to do what I want them to do?”

It’s a question borne out of frustration, and it is the question that strikes at the heart of what I consider the most important lens of W. Edward Deming’s System of Profound Knowledge: psychology or the human side of change.

Without understanding the psychology of change, efforts to build knowledge, understand variation, or appreciate the system will have limited success, if any. Unless we, as improvers, fully engage with the people most affected by change, the solutions will not be owned by them and are unlikely to produce sustained improvement.

Understanding the psychology of change leads to meaningful engagement and influences team culture. This builds capacity and capability for change in an organization so that improvement methodology becomes embedded in the system. In this way, we come closer to meeting that much quoted piece of wisdom from Paul Batalden: “Everyone in health care really has two jobs when they come to work every day: to do their job and to improve it.”

The SQSF program recognizes this and has developed educational opportunities to strengthen the ability of participants to engage with teams and demonstrate effective leadership. After learning about IHI’s Psychology of Change Framework, I challenged myself to see if we were delivering skills that advance the human side of change.

IHI’s Psychology of Change Framework brings together the practices necessary to activate people’s “agency.” Agency is defined as the ability of an individual or group to choose to act with purpose. It has two key components:

1) Power, or the ability to act with purpose;

2) Courage, or the emotional resources to choose to act in the face of difficulty or uncertainty.



As both a former fellow and current lead of the SQSF, I was struck by the alignment of IHI’s framework and our fellowship curriculum design. Some of the obvious connections include:

IHI Psychology of Change Framework

SQSF Curriculum

Unleash Intrinsic Motivation: Tapping into sources of intrinsic motivation galvanizes people’s individual and collective commitment to act.

Making Sense and Taking Action: Using Otto Scharmer’s Theory U, our teams approach change management by starting with opening people’s hearts and minds to make an emotional connection to the work.

Using Design Principles

Principles and tools used by service designers are introduced to help our teams uncover ideas that are important to staff and patients.

Co-Design People-Driven Change: Those most affected by change have the greatest interest in designing it in ways that are meaningful and workable to them.

Leading Individuals and Teams through Change: Our work focused on bringing all members of the team into the change process and recognizing that respectful inclusion in the change process is necessary for success. Transitions into new ways of working need to be handled in a sensitive manner and we discuss models used to guide such change.

Co-Produce in Authentic Relationship: Change is co-produced when people inquire, listen, see, and commit to one another.

Understanding and Working with Difference: Our teams make dedicated efforts to understand each individual and how different people can work best together.

The complexity of conversations is discussed in detail. The importance of understanding other perspectives and using this to constructively communicate is an important focus of discussions.

Distribute Power: People can contribute their unique assets to bring about change when power is shared.

Introduction to Human Factors: Our teams learn and explore individual biases and how they affect our work and ability to work together.

Culture and the Effects on Patient Safety: Our teams reflect on how behaviours, power, and hierarchy affect the ability of teams to deliver safe care.

Adapt in Action: Acting can be a motivational experience for people to learn and iterate to be effective.

Coaching Skills: Our curriculum takes leaders through a framework for coaching individuals and teams.


As with any training program, the real strength is in the expertise of the faculty. We call on organizational development expertise, senior clinicians with personal expertise, and even a former police negotiator to provide a unique experience for the participants. Participants note that the content makes them reflect on their own behaviour and come to the realization that, when trying to influence others, the first and only available step is to influence their own approach. This is the key to unlocking all the other techniques and helps us realize that our goal is not to “get someone to do something.” Our goal is to create the environment where agency can be activated to co-produce sustainable solutions.

I believe that thanks to the quality of our faculty and commitment of our fellows, the SQSF provides an educational offering that maps well to the five domains of the psychology of change and provides practical tools to use in real life situations. The evaluation of the training program suggests that the curriculum is well received. Fellows report changing their behaviours as they return to their workplace and use techniques to engage teams in improvement projects. The Psychology of Change Framework also aids our content review to continuously improve the program in service of activating our staff’s agency.

The psychology of change is the most challenging part of leading quality improvement projects. A framework that organizes how we can approach psychology is an invaluable resource to advance improvement!

Shobhan Thakore is the director of the Scottish Quality and Safety Fellowship.

You may also be interested in:

The IHI Psychology of Change Framework white paper

IHI’s Psychology of Change topic page

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