Leadership and Leadership and Communication for Communication for

Internal Spread Internal Spread Chinook LS 5Chinook LS 5

Mike Davies, MD FACPMike Davies, MD FACP

Mark Murray and AssociatesMark Murray and Associates

2Copyright Mike Davies, MD

Decreased Vision

Pre-op PE Questions RN over phone

F/U Phone Call

Optimist for glasses

Decreased Vision

Optimist for glasses

Ophthalmologist Dx Cataract & Completes Pre surgery Form &

Books Surgery

Surgery

GP Consults Ophthalmologist

Surgery

Post-op Ophthalmologist Visit

Nurse does PE Pre-op visit

Ophthalmologist Confirms DX

Optometrist DX Cataract/Refers to GP

12 Months vs 2 Months For Cataract Care

Simplification of the process in healthcare……….

3Copyright Mike Davies, MD

It’s NOT POSSIBLE to It’s NOT POSSIBLE to “Transfer” this “Transfer” this

Knowledge……. Knowledge……. Why?Why? Will to changeWill to change Leadership to create aimLeadership to create aim Involvement of allInvolvement of all Time to workTime to work Measurement of right thingsMeasurement of right things Unable to form new relationships Unable to form new relationships

neededneeded …….New knowledge not generated…...New knowledge not generated…..

4Copyright Mike Davies, MD

““Spread” is really adoption Spread” is really adoption (creation of new (creation of new

knowledge)…knowledge)… New knowledge must be created New knowledge must be created

by each team itself (adopted) by each team itself (adopted) rather than just “listened to” and rather than just “listened to” and implemented.implemented.

Adoption implies Adoption implies EFFORTEFFORT and and CHANGECHANGE

The knowledge The knowledge ONLY EXISTSONLY EXISTS in in the context of a teamthe context of a team

5Copyright Mike Davies, MD

Vision

Vision

Vision

Vision

Vision

Skills

Skills

Skills

Skills

Skills

ResourcesIncentives Action Plan

Incentives

Incentives

Incentives

Incentives

Resources

Resources

Resources

Resources

Action Plan

Action Plan

Action Plan

Action Plan

CHANGE

CONFUSION

ANXIETYGRADUALCHANGE

FRUSTRATION

FALSE STARTS

Managing Complex Change

6Copyright Mike Davies, MD

Late Majority

Early Majority

Early Adopters Historians

Innovators

Adopter Categories

2.5% 13.5% 34% 34% 16%

7Copyright Mike Davies, MD

Team ExerciseTeam Exercise

2-3 Volunteers to “sell” 2-3 Volunteers to “sell” somethingsomething

10-15 Volunteers to listen and 10-15 Volunteers to listen and decide if they want to buydecide if they want to buy

8Copyright Mike Davies, MD

What we learnWhat we learn

Diffusion curve shapeDiffusion curve shape Make a decision in 10 secondsMake a decision in 10 seconds Triggers of relative advantageTriggers of relative advantage People in the middle need more People in the middle need more

informationinformation People can be innovators on one People can be innovators on one

thing and laggards on another thingthing and laggards on another thing People don’t like to be called People don’t like to be called

laggardslaggards

9Copyright Mike Davies, MD

How you interact the How you interact the first 4 minutes dictates first 4 minutes dictates how your relationship how your relationship will go the rest of your will go the rest of your day will go.day will go.

Dr Dr PhilPhil

10Copyright Mike Davies, MD

Expert teamor individual

Receiving Team A

Receiving Team B

Receiving Team C

Knowledge

11Copyright Mike Davies, MD

Team B

Team D

Team A

Team C

Team F

Team EKnowledge

12Copyright Mike Davies, MD

The above maps represent the answers for two questions asked within the same physician network

Map of Technical Advice Seeking Network Map of Trust and Friendship Network

Figure 2

13Copyright Mike Davies, MD

14Copyright Mike Davies, MD

SpreadSpread

“BETTERIDEAS

Happens over time

COMMUNICATED

Thru a SOCIAL system

Adapted from Rogers, 1995

In a certain way

(C) 2001, Sarah W. Fraser

15Copyright Mike Davies, MD

Spread Readiness Spread Readiness ChecklistChecklist

� Access improvement is a Access improvement is a key key initiative initiative

� Senior Leaders are Senior Leaders are responsible responsible for, and engaged infor, and engaged in spreading the spreading the access/efficiency improvementsaccess/efficiency improvements

� Clear Clear intentintent to spread the work of to spread the work of the pilot teamthe pilot team

� The pilot team is The pilot team is successfulsuccessful and and relatively self sufficientrelatively self sufficient

16Copyright Mike Davies, MD

Where to StartWhere to Start The single biggest problem with The single biggest problem with

communication is the illusion that it communication is the illusion that it has taken placehas taken place - Bernard Shaw - Bernard Shaw

Tri-abilityTri-ability Compatible with values/beliefsCompatible with values/beliefs Social SystemSocial System 15-20% at each site is critical mass15-20% at each site is critical mass Innovators not listened toInnovators not listened to Early adopters ARE listened to Early adopters ARE listened to Spend most time with leadersSpend most time with leaders

17Copyright Mike Davies, MD

Influencing LanguageInfluencing Language ““Toward” Toward”

(Achiever)(Achiever) ““Away” Away” (Problem (Problem

Solver)Solver)

““Internal” (Leader)Internal” (Leader) ““External” External”

(Follower)(Follower)

““Procedures”Procedures” ““Options”Options”

..achieve, accomplish..achieve, accomplish

..wouldn’t be too hard..wouldn’t be too hard

..you might consider..you might consider

..thousands of others..thousands of others

..step-by-step..step-by-step

..pick and choose..pick and choose

18Copyright Mike Davies, MD

Influencing Influencing LanguageLanguage

TraditionalistTraditionalist EvolutionaryEvolutionary RevolutionaryRevolutionary

..same, similar, ..same, similar, familiarfamiliar

..improved, better,..improved, better,

new, breakthrough!new, breakthrough!

19Copyright Mike Davies, MD

20Copyright Mike Davies, MD

CultureCulture ““A force to be reckoned with”A force to be reckoned with” ““How we do things around How we do things around

here”here” ““Culture eats strategy for Culture eats strategy for

lunch every day”lunch every day”

21Copyright Mike Davies, MD

Culture is…Culture is… The unwritten values The unwritten values

reinforced every dayreinforced every day What it takes to “fit in”What it takes to “fit in” What it takes to “get What it takes to “get

along”along” Columbia/Challenger storyColumbia/Challenger story

22Copyright Mike Davies, MD

Observations About Observations About Medical CulturesMedical Cultures

Current CulturesCurrent Cultures Physician Physician

autonomy above allautonomy above all Financial Financial

incentives “magic incentives “magic bullet”bullet”

Consensus Consensus decision makingdecision making

Conflict AverseConflict Averse HierarchicalHierarchical Focus inwardFocus inward

Desirable CultureDesirable Culture Customer focusCustomer focus Continuous quest Continuous quest

for improvementfor improvement Collaboration Collaboration Personal Personal

responsibilityresponsibility AcknowledgementAcknowledgement

Adapted from Jack Silverstein

23Copyright Mike Davies, MD

The Way It Is With The Way It Is With CultureCulture

Culture change not for the Culture change not for the faintheartedfainthearted

QI projects alone unlikely to shift QI projects alone unlikely to shift deeply held culture values and deeply held culture values and behaviorsbehaviors

Senior leaders are key to shape Senior leaders are key to shape culture two ways:culture two ways: Signal generatorsSignal generators Hardwire into the organizationHardwire into the organization

Adapted from Jack Silverstein

24Copyright Mike Davies, MD

Signal Generation and Signal Generation and HardwiringHardwiring

25Copyright Mike Davies, MD

HardwiringHardwiring Leadership Leadership Structure for Structure for

communicationcommunication Structure for Structure for measuresmeasures AcknowledgementAcknowledgement and and

recognitionrecognition

26Copyright Mike Davies, MD

Leaders….Leaders…. Set prioritiesSet priorities Remove barriers and Remove barriers and

facilitate others taking facilitate others taking responsibilityresponsibility

Build trustBuild trust Go firstGo first CommunicateCommunicate

27Copyright Mike Davies, MD

Three Critical RolesThree Critical Roles

C h a m pio nC h a m pio n C h a m pio n

S po n s o r

A g e n t

28Copyright Mike Davies, MD

Key Change Team Key Change Team MembersMembers

Sponsors “I believe this is right”Sponsors “I believe this is right” Align resources – financial, people, Align resources – financial, people,

environ.environ. Monitor progressMonitor progress CommunicateCommunicate

Change agents “I will be the staff help”Change agents “I will be the staff help” No authority, but interpersonal skillNo authority, but interpersonal skill

Champions “I will sponsor change Champions “I will sponsor change locally”locally” Opinion leaders inside departmentsOpinion leaders inside departments

29Copyright Mike Davies, MD

Develop the Develop the MessengersMessengers

Choose the right messengersChoose the right messengersOpinion leaders Opinion leaders Connectors Connectors

Educate the messengers to Educate the messengers to deliver the messagedeliver the messageInclude peer-to-peer Include peer-to-peer communicationcommunication

30Copyright Mike Davies, MD

SHAREINFORMATION

SHAPE BEHAVIOR

“Marketing”flyersnewslettersvideosarticlesposters

PersonalAppealletterscardsPostcards

InteractiveActivitiestelephoneemailvisitsseminarslearning setsmodeling

Face-to-faceone-to-onementoringshadowing

Channels of Communication

PublicEventsRoad showsFairsConferencesExhibitionsMass mtgs

From Sarah W. Frasier

If I were king If I were king for a day……for a day……

32Copyright Mike Davies, MD

I would…I would… Make reduction of delay one of the Make reduction of delay one of the

top priorities for the organizationtop priorities for the organization Establish an influential oversight Establish an influential oversight

committee (with resources devoted to committee (with resources devoted to support it)support it)

Develop organization or service wide Develop organization or service wide goals outlining the steps to goals outlining the steps to implementationimplementation

Develop a robust system-wide Develop a robust system-wide compass of measurescompass of measures

33Copyright Mike Davies, MD

I wouldI would (cont.)………..(cont.)………..

Communicate the priority and goals at Communicate the priority and goals at every meeting every meeting

Communicate to key individuals privatelyCommunicate to key individuals privately Solve the problems effectivelySolve the problems effectively Celebrate success publicly and privately Celebrate success publicly and privately

by significantly acknowledging those by significantly acknowledging those responsible for changeresponsible for change

Promote leaders of like mind in this areaPromote leaders of like mind in this area

34Copyright Mike Davies, MD

Furthermore!Furthermore! Insist on regular meetingsInsist on regular meetings Rely on measurements to Rely on measurements to

improveimprove Continually look for Continually look for

improvement opportunitiesimprovement opportunities Acknowledge and celebrate Acknowledge and celebrate

successessuccesses

35Copyright Mike Davies, MD

VA Experience MDRC…VA Experience MDRC… 78 Medical Centers 78 Medical Centers Interviews, survey (3870 staff), Interviews, survey (3870 staff),

databases for wait time & patient databases for wait time & patient satisfactionsatisfaction

Found important predictors were:Found important predictors were:Extent of leadership supportExtent of leadership supportExtent of teams having & using Extent of teams having & using performance dataperformance data

Extent of knowledgeExtent of knowledgeTimeTime

Carol VanDusen Lukas, Mark Meterko

36Copyright Mike Davies, MD

How do we get How do we get there? there?

Your team Your team believes inbelieves in making Access work making Access work (WILL)(WILL) Your team makes reducing waits the top priority from now on Your team makes reducing waits the top priority from now on (WILL)(WILL) You must have the support of leadership You must have the support of leadership (WILL)(WILL) You must understand high leverage changesYou must understand high leverage changes (IDEAS) (IDEAS) Your “team” includes a physician, nurse and clerk at a minimum Your “team” includes a physician, nurse and clerk at a minimum

(EXECUTION)(EXECUTION) Your team has data – a compass of measures Your team has data – a compass of measures (EXECUTION)(EXECUTION) Your team tries and fails and tries again Your team tries and fails and tries again (EXECUTION(EXECUTION))

37Copyright Mike Davies, MD

Practical Strategies for Practical Strategies for Internal SpreadInternal Spread

38Copyright Mike Davies, MD

DefenderNeutralSupporter

Infl

ue

nce

Person A

x x

x x

Person B

x

x

xx

x x

x

x

x

39Copyright Mike Davies, MD

Bibliography and Bibliography and ReferencesReferences

Berwick. Berwick. A Primer on Leading the A Primer on Leading the Improvement of SystemsImprovement of Systems. . BMJ,BMJ, 312: pp 312: pp 619-622, 1996619-622, 1996..

Dixon. Dixon. Common Knowledge.Common Knowledge. Boston: Boston: Harvard Business School Press, 2000.Harvard Business School Press, 2000.

Fraser S. Spreading good practice; how to Fraser S. Spreading good practice; how to prepare the ground, prepare the ground, Health ManagementHealth Management, , June 2000June 2000

Gladwell. Gladwell. The Tipping Point. The Tipping Point. Boston: Boston: Little, Brown and Co., 2000.Little, Brown and Co., 2000.

40Copyright Mike Davies, MD

Bibliography and Bibliography and ReferencesReferences

Langley, Nolan, Nolan, Norman, Provost. Langley, Nolan, Nolan, Norman, Provost. The Improvement Guide: A Practical The Improvement Guide: A Practical Approach to Enhancing Organizational Approach to Enhancing Organizational PerformancePerformance. San Francisco: Jossey-Bass . San Francisco: Jossey-Bass Publishers., 1996.Publishers., 1996.

Rogers.Rogers. Diffusion of Innovations. Diffusion of Innovations. NY: The NY: The Free Press, 1962, 1983, and 1995.Free Press, 1962, 1983, and 1995.

Scholtes. Scholtes. The Leader’s Handbook: A The Leader’s Handbook: A Guide to Inspiring Your People and Guide to Inspiring Your People and Managing the Daily WorkflowManaging the Daily Workflow

41Copyright Mike Davies, MD

ReferencesReferences

Attewell, P. Technology Diffusion and Organizational Learning, Attewell, P. Technology Diffusion and Organizational Learning, Organizational ScienceOrganizational Science, February, 1992, February, 1992

Bandura A. Bandura A. Social Foundations of Thought and ActionSocial Foundations of Thought and Action. . Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986.Englewood Cliffs, N.J.: Prentice Hall, Inc. 1986.

Brown J., Duguid P. Brown J., Duguid P. The Social Life of InformationThe Social Life of Information. Boston: . Boston: Harvard Business School Press, 2000.Harvard Business School Press, 2000.

Cool et al. Diffusion of Information Within Organizations: Cool et al. Diffusion of Information Within Organizations: Electronic Switching in the Bell System, 1971 –1982, Electronic Switching in the Bell System, 1971 –1982, Organization ScienceOrganization Science, Vol.8, No. 5, September - October , Vol.8, No. 5, September - October 1997.1997.

Dixon, N. Dixon, N. Common KnowledgeCommon Knowledge. Boston: Harvard Business . Boston: Harvard Business School Press, 2000.School Press, 2000.

Fraser S. Spreading good practice; how to prepare the ground, Fraser S. Spreading good practice; how to prepare the ground, Health ManagementHealth Management, June 2000, June 2000

Gladwell, M. Gladwell, M. The Tipping Point. The Tipping Point. Boston: MASSBoston: MASSLittle, Brown and Company, 2000.Little, Brown and Company, 2000.

42Copyright Mike Davies, MD

ReferenceReference

ssKreitner, R. and Kinicki, A. Kreitner, R. and Kinicki, A. Organizational Behavior (2Organizational Behavior (2ndnd ed.) ed.) Homewood, Il:Irwin ,1978.Homewood, Il:Irwin ,1978.Langley J, Nolan K, Nolan T, Norman, C, Provost L. Langley J, Nolan K, Nolan T, Norman, C, Provost L. The The Improvement GuideImprovement Guide. San Francisco: Jossey-Bass 1996.. San Francisco: Jossey-Bass 1996.Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Lomas J, Enkin M, Anderson G. Opinion Leaders vs Audit and Feedback Feedback to Implement Practice Guidelines. to Implement Practice Guidelines. JAMAJAMA, Vol. 265(17); , Vol. 265(17); May 1, May 1, 1991, pg. 2202-2207. 1991, pg. 2202-2207. Myers, D.G. Social Psychology (3Myers, D.G. Social Psychology (3rdrd ed.) New York: ed.) New York:

McGraw-Hill, 1990.McGraw-Hill, 1990.Prochaska J., Norcross J., Diclemente C. In Search of How People Prochaska J., Norcross J., Diclemente C. In Search of How People Change, Change, American Psychologist, American Psychologist, September, 1992.September, 1992.Rogers E. Rogers E. Diffusion of InnovationsDiffusion of Innovations. New York: The Free Press, 1995. . New York: The Free Press, 1995. Wheeler, Donald J. Wheeler, Donald J. Understanding VariationUnderstanding Variation

SPC Press Knoxville, TN: 1993SPC Press Knoxville, TN: 1993

www.modern.nhs.uk/researchintowww.modern.nhs.uk/researchintopracticepractice www.sdo.ishtm.ac.ukwww.sdo.ishtm.ac.uk www.modern.nhs.uk/improvementguideswww.modern.nhs.uk/improvementguides