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Leadership for Performance Excellence
© Copyrighted Ontario Community Support Association 2014. All rights reserved.
© 2014 All rights reserved
The Quality Advantage: Agenda
Time Agenda Item
9:00 – 9:10 am Welcome and Introductions
9:10 – 9:30 am Objectives and Expectations
9:30 – 10:10 am Making the Case for Board/Senior Leader Focus on Quality
10:00 – 10:30 am Drivers for Effective Leadership: Knowledge, Roles, Skills:
Reflective Exercise
10:30 – 10:45 am BREAK
10:45 – 11:50 am Drivers for Effective Leadership: Culture:
Reflective Exercise
Drivers for Effective Leadership: Partnerships with Key Stakeholders
11:50am – 12:00 pm Questions?
© Copyrighted Ontario Community Support Association 2014. All rights reserved.
© 2014 All rights reserved
Workshop Objectives and Expectations
Objectives:
• Develop a shared understanding of the role of Boards & Senior Leaders in leading and overseeing the quality agenda;
• Discuss the key drivers for effective organizational governance and leadership of quality and safety;
• Reflect on current organizational practices relative to leading practices, and develop a plan of action for addressing gaps.
Expectations:
• What do you HOPE we discuss? What CONCERNS do you have about leading your organization’s quality agenda?
© Copyrighted Ontario Community Support Association 2014. All rights reserved.
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Making the Case for Board/Senior Leader Focus on Quality: What is the evidence?
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There are significantly increased expectations AND scrutiny of Boards, particularly in relation to the quality agenda
The work you have undertaken on your governance journey to date will not be sufficient to take you to where
you need to be tomorrow - what will your tomorrow look like?
ECFAA
MSAA
Accreditation
Public Expectation
Funding Reform
Research/ Evidence
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Where are we on the journey to excellence?
OECD Annual Comparison on Quality (Organization for Economic Cooperation and Development)
Ranked 10/11 Overall
Expended considerable effort on Access and ranked
11th
Ranked 7th for cost per capita
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2004: Canadian Hospital Adverse Events Study: • 7.5% of admissions
• 37% considered preventable
2013: 5 year Pan-Canadian Safety at Home Study:
• 10-13% dependent on data source
• 56% deemed preventable (falls, med errors, infections)
Where are we on the journey to excellence?
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The need to ‘bend the cost curve’ through new approaches
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OCSA Quality Advantage Baseline Survey Results, 2014
0
5
10
15
20
25
30
35
40
45
50
Very Familiar SomewhatFamiliar
Not Very Familiar Unsure
Familiarity with ECFAA
Per
cen
t
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Reasons: • Not enough time • Not the right staff • Waiting for mandate • Unaware of the Act
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Accreditation • 40% accredited & 12% in the process
• Of these, 4 most common agencies: • Accreditation Canada (40%) • Commission on Accreditation of Rehabilitation
Facilities (CARF) (22%) • Hospice Palliative Care Ontario (15%) • Canadian Centre for Accreditation (CCA) (9%)
Metrics • Only 38% report on quality metrics
QIP • 45% have a Quality Improvement Plan
(QIP) • 2/3 of those accredited have a QIP
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Are there studies that associate Board engagement with better clinical outcomes?
• Board establishes a Quality Committee
• Board sets the board agenda for quality
• Board sets strategic goals for quality improvement
• CEO and senior executives held accountable for quality and safety goals, frequently also tied to compensation
(Vaughn, Koepke, Kroch et al, 2006; Lockee, Kroom, Zablocki, Bader – Governance Institute/Solucient Top 100, 2006; Jiang et al, 2009 )
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• Board receives a formal quality performance measurement report
• Board uses indicators of quality and safety [in decision-making]
• CEO is identified as the person with the greatest impact on QI, especially when identified so by the QI Executive
(Vaughn, Koepke, Kroch et al, 2006; Lockee, Kroom, Zablocki, Bader – Governance Institute/Solucient Top 100, 2006; Jiang et al, 2009 )
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Are there any Canadian studies providing the same or different information?
• Ross Baker et al, Healthcare Quarterly 2010
(3 Canadian and 1 US case study, 15 pan-Canadian
interviews):
• Efforts are in early stages
• Concerned mostly with financial and access questions
• Board composition doesn’t always include individuals
with knowledge of quality and safety; few using a skills
matrix
• Most Boards receive voluminous indicators; no
information
• Organizations tend to struggle over compliance with
adherence to the Carver model
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The Excellent Care for All Act:
What are the requirements?
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ECFAA Requirements
• Quality committee of the Board
• Annual quality improvement plan, made publicly available
• Executive compensation linked to achievement of QIP performance targets
• Patient/client and caregiver surveys
• Employee/ care provider surveys
• Patient/client relations process, with information about the process publicly available
• Patient/client declaration of values, developed through public consultation
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Excellent Care for All Act and Associated Directives
Hospitals, 2010:
Bill 46: Excellent Care for All Act, 2010
Primary Care (CHCs, FHTs), 2013
Policy Directive, QIP only
Community Care Access Centres, 2014
Policy Directive, QIP only
Long Term Care Homes, issued 2014, but not mandatory until 2015
Policy Directive, QIP only
From Q&A: “all health care organizations should be striving to uphold the principles of ECFAA, putting their patients, clients, and residents first. “
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Proposed amendments to ECFAA re: patient engagement
March 24, 2014, draft Regulation under the Excellent Care for All Act (ECFAA), Patient Relations Process:
Processes for receiving, reviewing and attempting to resolve complaints expeditiously
Engage patients /caregivers in designing, reviewing & maintaining these processes
Appoint a patient relations delegate
Oversight with aggregate results to Quality Committee
• April 17, 2014 draft regulation under the Excellent Care for All Act
(ECFAA), QIPs:
• Patient engagement in development of Quality Improvement Plans (QIP)
• In QIP, describe patient engagement and how these activities inform development of the QIP)
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Reflect on your own organizations in relation to ECFAA readiness
Assuming that the MOHLTC implements the same requirements to CSS agencies as to other non-hospital sectors, would you say your organization:
1. Has some understanding of the ECFAA requirements, but will need a lot of support
2. Has the knowledge but will likely need some support
3. Has the knowledge and will not likely require any support
If OCSA was able to provide you with support, what kind of assistance would you be looking for?
© Copyrighted Ontario Community Support Association 2014. All rights reserved.
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Quality Frameworks for Boards/
Senior Leaders
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Governance Skills and Roles
Knowledge of Quality and [Client] Safety
Assess and Implement a Quality & [Client] Safety Culture
Relationship Between Board, Senior Leadership & [Key Stakeholders]
Measurement of Quality and [Client] Safety
Information on Quality and [Client] Safety
Create and Execute a Quality and [Client] Safety Plan
Drivers of Effective Governance High Impact Leadership
High Impact Behaviours: • Person-centred • Front line engagement • Relentless focus • Transparency • Boundarilessness
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Drivers for Effective Leadership for Quality:
Drivers 1 & 2: Knowledge/Roles/Skills
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The Board has the ultimate responsibility for quality and safety
The Board leads by, working with senior management, to:
Define quality/develop a framework for quality and safety
Ensure that the quality plan flows from the strategic plan
Identify board quality indicators to monitor
Develop its monitoring mechanisms and processes
Be actively involved in committee and board agenda design around quality
Embrace quality and become quality literate
Effective Governance for Quality and Patient Safety Education Program
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Considerations in establishing a Quality Committee
• Directors who are passionate about the agenda – preferably 1-2 members with quality improvement knowledge/experience
• Systems thinkers who will not be intimidated by the complexity of your service issues, who can frame probing, constructive questions & understand the answers – willing to be the minority in the room and challenge management
• Staff who can educate & support directors
• Consider making it mandatory practice for every new member of the board to rotate through the quality committee
“Credentials might get you on the Board, but your performance is what keeps you there.”
Leonard Berry, Texas A&M University
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Do you need a separate Board Quality Committee?
Options:
Separate (new) Quality Committee of the Board
Modify the mandate of an existing committee of the Board
Incorporate the terms of reference for a Board Quality Committee into the role of your full Board
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Current & desirable organizational performance
Resources (investments of time and money)
Risks and challenges that could impede achievement of targets
Timeline for results
Asking good questions!
Two important questions for Board members to ask is “Why?”
and to continuously question
“How will we know?”
Boards need the following knowledge to oversee progress on an improvement agenda:
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• How good are our services? • How do we compare to others like us? • How much of a gap is there
between our current and desired performance?
• Why does the gap exist and what is our plan to close the gap?
• How much variation is there
among our providers?
Key questions for Board members to ask…
AIM MEASURE CHANGE
Quality Dimension
Objective
Indicator
Current Performance
Target Target Justification
Change Idea
Method
Process Measure
Target Comment
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Key questions for Board members to ask…
Are our services getting better?
Are we on track to achieve our key quality and safety
objectives?
If not, why not?
Is the strategy wrong?
Is the strategy insufficient?
Is it not being executed effectively?
Is it too early in the process?
How many clients is that?
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Additional questions for Board members to ask…
What are the intended consequences?
What are risks? What are the unintended consequences?
Are there other options?
What if __________?
How will that impact our client outcomes?
How can we ensure continuity of performance excellence through succession planning?
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Reflection - Action Planning:
Knowledge, Roles, Skills
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BREAK
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Drivers for Effective Leadership for Quality:
Driver 3: Organizational and Board Culture
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Organizational Culture
Commit to a culture of continuous improvement where:
Staff feel safe to admit to error/failure: culture survey
It is recognized that failure is usually a system issue, and seized as a learning opportunity
There are processes for disclosure, apology, incident analysis to identify root cause
Organizational transparency of information:
Transparent internal measurement &
transparent systems for accountability
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No industry can define quality without the voice of the customer…
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Continuum of Engagement
Levels of Engagement
Consultation Involvement Partnership & Shared Leadership
Direct Care
Organizational Design &
Governance
Policy Making
Clients receive information
about diagnosis
Organization surveys patients about their care
experience
Public agency conducts patient focus groups to
ask opinions about an issue
Clients asked about treatment plan
preferences
Organization involves patients as advisors or
advisory council members
Client recommendations re: research priorities are used by public agency for funding decisions
Treatment decisions based on client
preferences, evidence, clinical judgment
Clients co-lead safety and quality
improvement committees
Clients have equal representation on
agency committees that make decisions
on funding for health programs
Adapted from Carman KL et al. (2013) Patient and Family Engagement: A framework for understanding the elements and developing
interventions and policies, Health Affairs, 32(2), 223-31
Nothing about me, without me….
Diane Pampling, Co-author, Healthcare in a Land Called
PeoplePower, 2001.
Changing norms/culture is difficult without
involving people from outside your system.
We can’t control what happens in healthcare
(clients’ diagnoses, condition), but we can
control the client experience!
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Board Culture
• Board ownership of and commitment to a Quality Plan
• Seen to be leading on the quality agenda
• Commitment to transparency and accountability
• Public access to board materials, results • Integration of clients/families
• Culture of inquiry, trust and candor at the Board, with an ability to operate in different modes (fiduciary, strategic, generative)
• Governing the quality agenda requires that Directors
understand operations.
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Board Culture will Trump Board Structure Every Time
Do you have concerns about getting too operational when discussing quality & safety? (Microgovernance)
At what point along the decision-making continuum should an issue be brought for generative discussion?
Is strategy only discussed at Board Retreats, or do strategic discussions occur at many of your regular Board meetings?
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Board Culture will Trump Board Structure Every Time
Is there always consensus on decision items?
Do you experience pinball governance?
Does the relationship between the Board and Executive Director support Board members challenging management on particular issues?
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Reflection – Case Study
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Drivers for Effective Leadership for Quality:
Driver 4: Partnerships with Key Stakeholders
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Consider new relationships given shared accountability for results & voluntary integration
MOU Contract
Shared staff resources
Are your relationships with service delivery partners sufficient to achieve your organizational goals?
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If not, what mechanisms might you use to strengthen these relationships for the future?
Partnership Continuum
Steering Committee
with ToR
MOU Formal Contract
No Documentation
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A Call to Action!!!
Engage in a relentless quest to make things better.
As long as improvement is seen as something outside
the core work of the organization, as long as it is viewed as “something else to do”,
operational excellence will remain elusive.
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David Hughes
Director, Member Services T: 1-800-267-6272 ext. 246 [email protected]
Sue Davidson
Director of Training T: 1-800-267-6272 ext. 273 [email protected]
Contact Us!
Paula Blackstien-Hirsch Principal
T: 905-771-0981 [email protected]
© Copyrighted Ontario Community Support Association 2014. All rights reserved.