Creating Healthy Cultures for Health Units

March 21, 2018

DISCLOSURE OF COMMERCIAL SUPPORT

• Presenters: • Susan Taylor, Director and CNO, Haldimand-Norfolk Health Unit• Marlene Miranda, General Manager, Health and Social Services, Norfolk

County• Agnes Zabinska, Public Health Nurse, Haldimand-Norfolk Health Unit• Dr. Madelyn Law, Associate Professor, Department of Health Sciences, Brock

University; Director of I-EQUIP • None of the presenters at this session have received financial support or in-

kind support from a commercial sponsor. • None of the presenters have potential conflicts of interest to declare.

Session Objectives

Describe the critical success factors for inclusion in the design of an effective quality improvement approach that can be scaled to the Health Unit as a whole

Describe the value proposition of large scale investment in training and the measurement framework that will reflect the success of an organization wide initiative to create a quality culture

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Setting the Context:Haldimand-Norfolk Health Unit

Heath Unit serves Haldimand and Norfolk counties Rural communities across large geography, total population ~ 110,000 99 staff make up total complement of ~ 87 FTE

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Setting the Context: Public Health Landscape in early 2017

Integration of PH within sub-region resources (Patients First and LHIN work stream)

Anticipation of new Ontario Public Health Standards, and expectation that will require changes in services and priorities

Uncertainty with recommendations from Expert Panel Report and subsequent challenges

Ongoing challenges with maintaining services given fiscal constraint

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What were we trying to accomplish?

Enhance ability to engage in healthy dialogue to work through issues together to achieve a common goal

Build leadership capacity throughout organization Realize potential from resources and optimize outcomes

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Designing for Scalable, Sustainable Change

Create the conditions for success Build improvement capability at scale - Design QI into jobs Address sustainability

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Creating the Conditions for SuccessBuilding capacity for change at scale

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Establish Principles

“All in” – all levels, all roles to signal importance of everyone’s contributions

Target relentless incremental improvement “Enjoy the struggle” No shame, no blame! Let’s try it! Interactive/spiral learning Collective wisdom “Just enough” – time, data, people Set scope to be achievable in the time frame Support and stay out of the way 9

Anticipate and Prepare for Conflict

RECOGNIZE that as soon as disrupt the status quo, there will be tension Imperative to give all members of staff a common framework to address

conflict DEVELOP STAFF through mandatory “Crucial Conversations”

workshops to level set and build capacity to engage collectively 87% (78 of 90) staff participated in workshop

85% attendees responded agree or strongly agree to the statement “Participation in this workshop has increased my practical knowledge and will help me problem solve when faced with a crucial conversation” (target 80%)

IMPACT today it is not unusual to hear language like “and that’s a story I tell myself”…

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Develop Formal and Informal Leaders

RECOGNIZE that if we accept status quo, there will be missed opportunities and we will not realize true potential of organization

DEVELOP STAFF through training and experiential learning Approximately 75% staff attended “Adaptive Leadership” workshop

Staff have rotated through the Team Lead role for the QI working groups

IMPACT today that we have created opportunities and roles that have strengthened the leadership competencies and increased confidence throughout the staff team

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Support Managers

RECOGNIZE that there will always be competing demands in a climate of substantive change

DEVELOP STAFF through introduction to “Polarity Management” to help change the conversation from A or B to A and B

IMPACT today that while it is still not perfect, Managers have different tools in their toolkits to engage in productive conversations with the team, and that we have an ever-increasing shared understanding of what we can do to support one another.

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Building Improvement Capability at ScaleDesigning QI into All Jobs

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Teach People HOW

RECOGNIZE that there is a science behind quality improvement, and it is this rigour that delivers value. There are a number of different approaches, but there is merit to all following the same framework.

DEVELOP STAFF by providing mandatory IDEAS (Improving and Driving Excellence Across Sectors) Foundations in Quality Improvement training to all staff IDEAS is supported by the MOHLTC and utilized across all sectors, so this

will have added benefit of preparing staff in Public Health to speak the same QI language

96% (95 of 99) staff have participated in 1 day workshop and completed online modules

IMPACT today – Staff are engaged in a rigorous and consistent approach to quality improvement 14

Apply the Learning

RECOGNIZE that as adult learners, we need the opportunity to practice to solidify learning

DEVELOP STAFF understanding through a series of increasing complex initiatives

IMPACT today that staff have participated in at least two initiatives and are currently engaged in a third

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Apply the Learning

Cohorts 1 and 2 - Applied QI science to solidify learning from IDEAS Foundations in Quality Improvement We used the term “cohort” to signify that these initiatives were part of the

application of learning.

Advisory group of front-line and management staff Identified initiatives selected based on prioritized list of “irritants” –

The things that leave us feeling frustrated, end up taking a disproportionate amount of time and/or energy to accomplish, and if we could improve, would free us up to spend more time doing the things that are most important.

Assigned staff to be members of QI Teams, based on Guiding Principles 16

Cohort 2:May 23-Aug 17, 2017

Cohort 1:Apr 27-Jul 20, 2017

Apply the Learning

Guiding Principles for forming the groups. The individual groups will describe their own principles for how they will work together. Have a mix of areas of expertise on each group, ensuring that some

members have subject-matter expertise related to the topic Have a mix of disciplines and of program teams Address a topic relevant to the participants Have a mix of senior and newer staff Ensure inclusion of all staff from the Health Unit Target a group size of 8 (minimum of 6 and maximum of 10) Gave option to switch groups as long as principles maintained

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Cohort 2:May 23-Aug 17, 2017

Cohort 1:Apr 27-Jul 20, 2017

Reflections on Experiencing “Healthy Public Health”Agnes Zabinska

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Give People Experience

Wave 3 - Applied QI science to ongoing initiatives We switched terminology from “cohort” to “wave” to signify that this was

now part of the ongoing process.

Initiatives reflected “irritants”, as well as beginning to incorporate more program delivery options

Staff were invited to sign up to the initiative that interested them using modified Guiding Principles (added consideration for balancing full-time, part-time staff)

Introduced six dimensions of quality into description of initiatives (safe, effective, efficient, person-centred, timely, equitable)

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Wave 3: Sept 25-Dec 15,

2017

Reflections on Experiencing “Healthy Public Health” – Wave 3

Agnes Zabinska

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Embed Learning into Practice

Wave 4 – Initiatives related to work of functional teams Topics selected by Program Managers with input from staff, and with

knowledge of where there were opportunities to improve based on the dimensions of quality

Extended the timeline to 11 months to allow for richer exploration and full implementation of solutions, as well as to build in opportunities to pause briefly during peak demand

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Wave 4: Jan – Dec, 2018

Supporting Staff to Learn and Apply

Set Expectations – explicit that this was an expectation for all staff, and that training was mandatory

Protected Time – expectation that an average of 2 h per week will be spent by all staff on quality improvement activities

Provided Coaching – used gapping dollars to hire experienced Improvement Advisor for ~ 6-10 h/week during the initial initiatives to coach teams through application of QI tools and processes

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Celebrate Success!

Get to know people and have fun together Recognize one another’s contributions Gain momentum Share outcomes from the initiative (KTE) AND

learning from the process – remember, there is as much to learn from the

things that don’t go well as the things that do!

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Sustaining the Change

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Set Expectations

Added language to all new postings for the Health Unit (non-union and union), as follows: Contribute to the identification and prioritization of areas for

improvement within the six dimensions of quality (safe, effective, efficient, timely, person-centred and equitable).

Engage with colleagues in a systematic approach to quality improvement, including the definition of the purpose and scope; development, testing and implementation of change ideas; and measurement of reach and impact.

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Reinforced Expectations – each Wave

All Health Unit staff are responsible for contributing to the QI initiatives included within Healthy Public Health: Creating a Quality Culture Together!

Commit to attend team meetings, recognizing that there may be occasional conflicts

Adhere to the team norms as defined by the team Use QI tools to contribute to the development of a problem statement

and corresponding aim statement Participate in PDSA cycles to develop, test, implement and sustain the

change Share their knowledge freely in recognition of their unique viewpoint

(“All teach, all learn” philosophy)26

Protected Time

Continued to expect that all staff will commit an average of 2 h per week to improving their respective programs

The return on investment for this time will be reflected in all six dimensions of quality

Built in some flexibility in Wave 4 given learning in previous initiatives, in that there are seasonal peaks that vary by team and created tension in very short initiatives

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Introduced Executive Sponsors – Wave 3

The Executive Sponsor is not a member of the working group, but is involved from the perspective of ensuring that the team has the resources it needs to be successful.

The Executive Sponsor will: Consult with the Team Lead to guide scope, assign resources and address

barriers

Demonstrate visible leadership (Go out to where the work is being done) and engage staff (will and motivation)

Co-ordinate this initiative with others (internal and external to the organization), as applicable

Communicate shared purpose & progress to staff and stakeholders28

Established Peer QI Coaches – Wave 4

Team of 4-6 individuals available to assist their colleagues with using the quality improvement tools and processes learned through IDEAS.

While Peer QI Coaches are still learning, they have demonstrated a level of comfort with the tools that will allow them to support others in the QI journey.

The inclusion of an experienced Improvement Advisor during the first few months was a critical success factor, and the introduction of Peer QI Coach makes the support sustainable.

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Introduced QI Communications and Knowledge Exchange Team – Wave 4

Team of 4-6 individuals available to assist in sharing the progress of teams and helping others think about how they might adapt learning from one team to another circumstance.

Spend an average of 2 h a week supporting other teams communicate their journey through QI through storyboards (and other creative approaches)

As QI teams reach maturity, they will help identify and articulate lessons learned to be shared internally or externally with other health units

Identify vehicles for sharing and support 2-3 teams to submit and prepare (could be presentations, posters or publication).

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Established Steering Committee to Provide Guidance – Wave 4

Deliverables: Inform the pacing and sequencing of high level milestones Monitor progress of QI Teams Communicate progress and lessons learned Evolve supports to address critical success factors Promote ongoing sustainability of previous initiatives Create a process to inform selection of QI initiatives Create an annual process to nominate and select the Peer QI Coach

Team and Communications and Knowledge Exchange Team members.

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Reflections on Alignment and SpreadMarlene Miranda

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Embed a QI approach in culture of Health Unit

Spread QIknowledge and practice to other departments

Embrace“Our Culture” across the HSS division

Evaluating the Investment in Teams

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Year 1: Building Capacity to Engage in QI

Aim: By December 2017, 100% HNHU staff will have the capacity to apply

foundational Quality Improvement tools and methods and will contribute to at least one improvement initiative that impacts their work in the Health Unit.

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Outputs: Reach

Staff has been introduced to the fundamentals of QI, and applied new concepts and skills to an actual “irritant” in their workplace.

100% (90 of 90) of staff completed a self-assessment of their skills before beginning, creating a valuable baseline measure.

100% (10 of 10) of Wave 3 teams shared their accomplishments and learning at a Sharing Symposium in December, including a summary “tree diagram” to describe their initiative in preparation for sustaining the gains. These diagrams described process measures (“are we doing the things we said we’d do”) and outcome measures (“are we getting the results we need to get”).

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Short-Term Outcomes: Learning & Usefulness

Staff has enhanced their competence and confidence to resolve disagreements, learning to speak persuasively, and foster teamwork.

100% of teams systematically completed the QI milestones following a logical, structured approach that prepares teams to reconfigure with minimal disruption.

100% of Wave 3 participants engaged in one of 10 QI initiatives designed to solidify their learning while achieving practical process improvements.

Participants embraced the process and actively contributed to the evaluation of the efforts.

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Intermediate Outcomes: Actions & Use

Creation and use of QI charter to guide work, and Application of foundational QI tools, including problem/opportunity

statement, root cause analysis, process mapping, PDSA cycles, to a series of increasingly complex initiatives Cohort 1: 100% (5 of 5)

Cohort 2: 100% (5 of 5)

Wave 3: 100% (10 of 10)

Wave 4: 11 initiatives (in progress)

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Long-Term Outcomes: Impact

Inclusion in job description of expectation for all staff to contribute to QI efforts

Expansion of internal capacity through Peer QI Coaching Team and Communication and Knowledge Exchange Team

Increasingly sophisticated measures possible as we move into year 2 –will leverage the Steering Committee to guide development of renewed logic model

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What We’ve Learned…So Far…

It takes time to see results. Be patient. Changing behaviour takes time, whether it is to improve

processes or to engage in quality improvement as the approach.

It takes time and energy to engage. It is essential to protect time for staff to engage and leverage energy to

build momentum.

The investment in quality improvement is an investment in the team. Impact will be measured over a period of many years. We will learn as

much from what doesn’t go well as from what does.

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Reflections – Connecting Theory to PracticeDr. Madelyn Law

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