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In 2017, IHI’s innovation team began exploring the psychology of change — the science and art of human behavior as it relates to transformation. The team reviewed the literature and conducted interviews with experts in a wide variety of disciplines to better understand how to increase the success and sustainability of improvement projects. This eventually led to the development of the IHI Psychology of Change Framework. The following is an excerpt from the IHI Psychology of Change Framework to Advance and Sustain Improvement white paper.

Activating people’s agency is the central objective of the IHI Psychology of Change Framework. Activate means to make active or more active, or to convert from inactive to active. Agency is defined as the ability of an individual or group to choose to act with purpose. Agency has two key components: 1) power, or the ability to act with purpose; and 2) courage, or the emotional resources to choose to act in the face of difficulty or uncertainty. Together, courage and power are the primary drivers for activating people’s agency, or the ability of an individual or group to choose to act with purpose.

Imagine, for example, a hospital postoperative surgical unit that has a high rate of avoidable patient falls. A unit staff nurse has ideas about how to prevent falls, but he is responsible for many specific tasks and has little time to change the standard work on the unit. He views his power — his ability to act to prevent falls — as limited; he does not believe that he has the requisite skills to initiate an improvement project. Moreover, he fears punishment: he believes from previous experience that working outside of the unit’s standard practices can result in disciplinary action. His willingness to choose to act to prevent falls is minimal; his courage is constrained by the organization’s operational norms. To engage in meaningful improvement and advance a process for change, leaders need to identify ways to activate the staff nurse’s agency — both his power and his courage — to result in the mindful choice to act.

Power: The Ability to Act with Purpose

Power is not a position or title that a person has within an organization; it’s not a thing, quality, or trait. Power is relational; it is produced by a set of interdependent relationships that can be leveraged to achieve a specified aim. Power is generated as people bring to bear their skills, knowledge, experience, and capacity to act, individually and together, to achieve an aim.

Courage: The Emotional Resources to Choose to Act in the Face of Challenge

The root of the word courage is “cor,” the Latin word for heart. Courage comes from people’s emotional resources for mindful choice to act in the face of challenge. Educator Parker Palmer explains that the source of courage is in knowing ourselves, creating circumstances in which others can become more self-aware and self-knowing, and being in relationship with what is happening around us.

The IHI Psychology of Change Framework is centered on activating agency at three levels:

• Self — An individual’s agency to make his or her own choices. People feel an increased sense of agency when they exercise their power and courage to take action.
• Interpersonal — The collective agency of people acting together. People feel an increased sense of agency when they encounter positive experiences of other people exercising power and courage.
• System — The structures, processes, and conditions that support the exercise of agency within and across institutions and organizations. People feel an increased sense of agency when the structures within which they operate enable them to exercise their power and courage.

This is the objective in the IHI Psychology of Change Framework: to create the conditions that enable individuals and groups across systems to exercise power and courage (i.e., to choose to act with purpose) to advance and sustain improvements in health and health care.

To learn more about the psychology of change methodology, read the IHI Psychology of Change Framework to Advance and Sustain Improvement white paper.

You may also be interested in:

Quick Course Q1 Psychology of Change: A Human-Centered QI Approach at the IHI National Forum (December 9–12, 2018 in Orlando, FL, USA).

Why Good Ideas Aren’t Enough to Sustain Improvement

WIHI: How to Make Change Happen: An Introduction to IHI's Psychology of Change Framework