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6/10/2015
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Leading Quality Improvement
Essentials for ManagersSession 9: Empower Teams to Engage in
Improvement
June 9, 2015
These presenters have
nothing to disclose
Janet Porter, PhDKathy Duncan, RN
Today’s Host2
Dorian Burks, Project Coordinator, Institute for
Healthcare Improvement, is a current coordinator for
web-based Expeditions. He also contributes to the IHI
work in the Triple Aim and Improvement Capability
focus areas, as well as the Leading Quality
Improvement series. Dorian is a member of the
Diversity and Inclusion Council at IHI, where he and
fellow staff members develop strategies to enhance
IHI’s inclusive culture, both internally and externally.
Dorian graduated from Massachusetts Institute of
Technology in Cambridge, MA where he received his
Bachelor of Science degree in Biology and humanities
concentration in Anthropology.
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Kathy Duncan, RN6
Kathy Duncan, RN, Faculty, IHI, co-leads IHI's National
Learning Network. Ms. Duncan also directs IHI Expeditions,
manages IHI's work in rural settings, and provides spread
expertise to Project JOINTS. Previously, she co-led the 5
Million Lives Campaign National Field Team and was
faculty for the Improving Outcomes for High Risk and
Critically Ill Patients Innovation Community. She also
served as the content lead for the Campaign's Prevention
of Pressure Ulcers and Deployment of Rapid Response
Teams areas. She is a member of the Scientific Advisory
Board for the AHA NRCPR, NQF's Coordination of Care
Advisory Panel, and NDNQI's Pressure Ulcer Advisory
Committee. Prior to joining IHI, Ms. Duncan led initiatives to
decrease ICU mortality and morbidity as the director of
critical care for a large community hospital.
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Today’s Agenda7
Review of Session 8
Empower Teams to Engage in
Improvement
The Sarah Kadish Case
Final Thoughts
Charmaine VanHeerden – Thanks! Elements of a culture of safety Review for your area of responsibility An Action I can take to improve the culture of safety
Make Safety a core value – the role of leaders
Leadership is on board, regular safety rounds conducted by EHS & ICD
Encourage front-line senior nurses to be more vigilant with maintaining the standards and reporting gaps
Provide Strong leadership at all levels There is strong leadership available but not at all levels
Empower necessary staff members with the needed knowledge and skills to perform their required duties regarding safety
Model and demand desired behaviors -
Few of us do, but once again not consistent on all levels
Request more participation from managerial positions to demand desired behavior and more couching of staff involved
Be reluctant to simplify This is an area of concern as most of the things gets blamed on incompetent nurses or too busy unit
Demand for in-depth investigation from Quality Department and encourage submission of Occurrence Reports emphasizing a Just Culture and No-Blame Environment
Empower individuals to successfully fulfill their safety responsibilities
Regular EHS and ICD in-services are available also frequent refreshers on the JCIA Patient Safety Goals
Consistent and intense reinforcement of safety guidelines. Encourage culture of learning
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Charmain VanHeerden – Thanks!
Accept deference to expertise For every safety problem we encounter in the unit, there is an outside Department of expertise
Involve other departments of expertise for education and safety input
Foster mutual trust and transparency: Psychological safety
Focusing on Just Culture but still have staff reluctant to report occurrences as they feel it is “finger pointing” for punishment
Reinforce the No-blame culture. Cough and teach accountability even for the fact of not reporting
Ensure open and effective communications: teamwork
We have in place shift Huddles, CUSP meetings, monthly unit meetings
Units are sometimes too acute for shift Huddles – try to be more vigilant with implementing Huddles as this is a good tool of communication for teamwork. Bed to bed engagement with bedside nurses, buddy systems
Provide timely response to safety issues and concerns: Fair and Just Culture
Does not always happen that we here the follow-up from reporting concerns
Demand more timely response from managerial positions
Provide continuous monitoring of performance
ICD and EHS do very regular monitoring of performances but once again, not consistent monitoring from all levels in front-line nursing
Make bedside nurses more aware of safety measurements by involving them in auditing
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Janet Porter, MBA, PhD10
Janet Porter, MBA, PhD, a principal with Stroudwater Associates, serves as a strategy, operational, and leadership development consultant to hospitals and physician practices. Dr. Porter served as the Chief Operating Officer of Dana-Farber Cancer Institute; the Associate Dean of Executive Education at the University of North Carolina’s School of Public Health; the Interim CEO of the Association of University Programs in Health Administration (AUPHA); and the Vice President, and then COO of Nationwide Children’s Hospital in Columbus, Ohio. Currently teaching strategic management in the Healthcare Executive MBA program at the University of Miami, Dr. Porter is also an active adjunct professor at the University of North Carolina at Chapel Hill and Ohio State University. Janet serves on the AARP board of directors and the High-Value Healthcare Collaborative Advisory Board. Janet received her BS and MHA from Ohio State University, and her MBA and PhD in health care strategy from the University of Minnesota.
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Today’s Agenda11
Review of Session 8
Empower Teams to Engage in
Improvement
The Sarah Kadish Case
Final Thoughts
Manager vs Leader12
©2010 Creative Health Care Management
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Empower and Engage
Engage
Involve somebody in an activity, or become involved or
take part in an activity
Empower
To give somebody power or authority
To give somebody a greater sense of confidence or
self-esteem
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Encarta Dictionary
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Employee Engagement
Gallup, (2013). State of the American Workplace
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The Impact of Employee Engagement
Gallup, (2013). State of the American Workplace
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Focused Leadership = Engagement
Gallup, (2013). State of the American Workplace
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Four Elements of Healthy
Interpersonal Relationships
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©2010 Creative Health Care Management
Trust
To trust means to have
confidence and belief. When trust exists,
there is a more relaxed way of being
and less energy is spent on
managing the relationship.
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©2010 Creative Health Care Management
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Mutual Respect
In environments of mutual respect
people feel seen
and they feel that their voices and
perspectives are invited and valued.
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©2010 Creative Health Care Management
Six Ways to Empower Your Team
Encourage In-The-Moment Feedback
Cultivate the Executive Mentality
Present New Challenges and Opportunities
Respect Boundaries
Give Them Flexibility
Don’t Babysit
Six Ways to Empower Your Employees with Transformational Leadership,
Forbes, December 27, 2014
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Today’s Agenda21
Review of Session 8
Empower Teams to Engage in
Improvement
The Sarah Kadish Case
Final Thoughts
Phase I: Plan
What are the first things that have to
happen for improvement to take place?
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See the Problem:
Reducing Wait Time at Dana-Farber
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Measure the Problem:
Process (and Wait) Time
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Phase I: Plan
Like many quality improvement
initiatives, this problem seems
intractable. What must be in place to
really have an impact on an intractable
problem?
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Connect to Mission, Strategic Plan
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Understand Patient Flow
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Measure: Breast Cancer Patients
Wait Time by Time of Day
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Define
Six Sigma
Analyze
Measure
Improve
Control
Identify Value
Understand Value Stream
Eliminate Waste
Establish Flow
Enable Pull
Pursue Perfection
Lean
Source: The Improvement Guide, API
Approaches to Improvement
Phase I: Plan
How does Sarah get started? Where to
begin?
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Understand System: processes and
interactions at all levels
Governance
Therapies
Leadership
Supply Chain
TransitionEvaluation
Management
FacilitiesHR
Entry
Staff
I.T.Revenue
Cycle
Drivers
Mainstay
Support
The Patient
Develop an Integrated Work Plan P32
IHI’s framework for spread (Nolan, Schall et al. 2005)
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Develop an Approach
Phase I: PLAN Understand the problem, build a case, measure
Phase II: PILOTTest the feasibility with pilot
Phase III: SPREADSpread intentionally to maximize learning
Phase IV: SCALE Bring to scale
2009
2010
2011
2015
Learn &Revise
Learn &Revise
Learn &Revise
34Build A Team
Common Goal/PurposeDefined Roles to
PlayAgreed Upon Rules
of EngagementPerformance MeasuresLearn Together
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Phase II: Pilot
What tools should Sarah use to
design the pilot?
Where should the pilot take place?
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Piloting Results to Take to Scale
Taking the
Change to Full
Scale
Developing a change
Implementing
a change
Testing a
change
Act Plan
Study Do
Theory
and
Prediction
Test under a
variety of
conditions
Make part
of routine
operations
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Examples of Tools
Affinity Diagram
Brainstorming
Control Charts
Fishbone Diagrams
Flow Chart
Gantt Chart
Histogram
Matrix Diagram
Pareto Diagram
Radar Chart
Scatter Diagram
Value Stream Map
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Fishbone Diagrams38
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• Two weeks of observation pre-work
• Split into 8 teams and walked the value stream
• Collected voice of the customer and identified process waste
• Documented waste and re-work in the process and mapped a high level current state value stream map
Picture
Value Streams
Scorecards
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Satisfaction Financial Quality Growth
Outcome Metrics
Reason For Miss
A3s
ProcessMetrics
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Who and Where to Test?41
Phase II: Pilot
What can Sarah do to effectively lead
a team that does not report to her?
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Define Interconnected Responsibilities
• Do the Standard Work
• Surface Problems
• Solve those that they can
• Improve the Standard Work
Staff
• Observe, Measure, Analyze, Action
• Coach the Front Line
• Support and Lead the Improvements
• Manage the Project
Management• Align to Strategy
• Develop the System and Structures for Support
• Coaching in the Work
• Steward the Changes
Executive
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Performance Improvement, Decision Support, HR, I.T. Facilities
Coaching vs Commanding
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Commanding
Routine Urgent Emergent
Coaching
• Engaging
• Collaboration
• Complexity
• Fluid
• Controlling
• Compliance
• Simplicity
• Rigid
Adaptive: Help Coachee
to think for self
Directive: Think for coachee
Collaborative:Think with coachee
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Coaching
• “Coaching in its truest sense is giving the responsibility to the learner to help them come up with their own answers.”– Vince Lombardi
• A manager’s task it simple---to get the job done and grow his or her staff. Time and cost pressures limit the latter. Coaching is one process which accomplishes both. – John Whitmore
Phase II: Pilot
What support systems would need to
be in place for the pilot to work?
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Phase II: Pilot
What support systems would need to
be in place for the pilot to work?– Information systems (tested RTLS software)
– Human resources (training of staff)
– Physical systems (computers, badges, RTLS ceiling monitors)
– Delivery systems (systems for distributing, cleaning, sanitizing,
charging and collecting the badges)
– Financial structures (operating and capital budgets, possibly
financial incentives)
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Phase III: Adoption and Spread
What could Sarah and the team do to
persuade reluctant staff to participate in
RTLS?
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People who
adopt new ideas
go through these
five stages!1. Awareness
2. Persuasion
3. Decision
4. Implementation
5. Confirmation
Stages of Adoption
Prochaska J, Norcross J, Diclemente C. In Search of How People
Change, American Psychologist, September, 1992.
Phase III: Adoption and Spread
How might patients and families and/or
PFACs be involved in designing and
testing RTLS?
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Patient Engagement Framework
Patient Engagement in Their Own Care“Shared Decision-Making”
• Portals for Patient Access to Information• Educational Tools and Provider Training
Patient Engagement in Clinical Quality Improvement and Safety• Process Improvement (Lean: Kaizens, Workouts)
• Disease-Specific Protocols
Patient Engagement in Patient Experience Improvement• Patient Satisfaction Committees
• HCAHPS
Patient Engagement in Organizational Decision-Making• Patient and Family Advisory Committees
• Governing Board Roles
Specific to Patient (Individual)
Specific to Disease(Dept/Unit)
Specific to Quality(Organizational)
General(Organizational)
Phase IV: Scale
What should Sarah do to scale RTLS
throughout Dana-Farber to optimize
opportunity to reduce wait time?
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Relative Advantage
Simple Trialable Compatible Observable
Attributes of an Idea that Facilitate Adoption
Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press.
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If you want to go FAST, go SMALL
Learn quickly and go BIG, FASTER
Rapid cycle small scale testing
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Phase IV: Team Longevity
What should Sarah do to keep the
team focused over time?
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56Sustain A Team
Common Goal/PurposeDefined Roles to
PlayAgreed Upon Rules
of EngagementPerformance MeasuresLearn TogetherUpdate GoalsRecognize and Celebrate!
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Resources
Team of Teams. New Rules of Engagement for a Complex World. General
Stanley McChrystal. 2015
Gallup (2013). State of the American workplace. Located at
http://www.gallup.com/strategicconsulting/163007/state-american-
workplace.aspx.
Sinek, S. (2010). How great leaders inspire action. Located at
https://www.ted.com/talks/simon_sinek_how_great_leaders_inspire_action#.
Swensen S, Pugh M, McMullan C, Kabcenell A. (2013). High-Impact Leadership:
Improve Care, Improve the Health of Populations, and Reduce Costs. IHI White
Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement.
(Available at ihi.org)
Ask Your Team
If anything was solvable, what problem would you solve
that would have the greatest impact on patient care?
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Today’s Agenda59
Review of Session 8
Empower Teams to Engage in
Improvement
The Sarah Kadish Case
Final Thoughts
Objectives
At the end of the program, participants will be able to:
Describe the skills, tools, and resources needed by
a middle manager to lead quality improvement
efforts in their local settings
Demonstrate how to link department-level
improvement activities to the organization’s goals
and overall strategic plan
List at least three ways middle managers can be
successful in partnering with front-line staff in quality
improvement activities
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“Everyone in healthcare really has two jobs when they come to work every day:
to do their work and to improve it.”
Paul Batalden, MDSenior IHI Fellow
Additional Resources
Institute for Patient and Family Centered Care (ipfcc.org)
IPFCC Toolkit (http://www.ipfcc.org/tools/Patient-Safety-Toolkit-04.pdf)
Arnold P. Gold Foundation (humanizingmedicine.org)
Anna Quindlen Address (http://humanizingmedicine.org/anna-quindlen-advises-physicians/
Agency for Healthcare Research and Quality (http://www.ahrq.gov/research/findings/final-reports/ptfamilyscan/index.html
American Hospital Association (http://www.aha.org/advocacy-issues/communicatingpts/pt-family-centered-care.shtml)
Institute for Healthcare Improvement (http://www.ihi.org/offerings/Initiatives/PatientFamilyCenteredCare/Pages/default.aspx)
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to access the IHI Open School: http://app.ihi.org/lms/home.aspx/EssentialsForManagers
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LQI Follow-up & Communications
All sessions are recorded
Continuing Education credit instructions will be sent out
via email
Listserv address for session communications:
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LQI Post-Survey
We’d love to hear your feedback! After this session ends,
you will be redirected to the post-session survey – please
fill out and we will work to make next year the best LQI yet!
https://www.surveymonkey.com/s/SSKPRRB
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Thank You from the Leading Quality
Improvement Team!
Kathy D. Duncan, RN
Director, IHI
Jill Duncan, RN, MS, MPH
Director, IHI
David Munch, MD
Senior Vice President
and Chief Clinical
Officer, Healthcare
Performance Partners
Janet Porter, MBA, PhD
Principal,
Stroudwater Associates
Kayla DeVincentis, CHES
Project Manager, IHI
Dorian Burks
Project Coordinator, IHI
