clinicalmicrosystem.org M8:The Micro/Meso/Macrosystem ...app.ihi.org/FacultyDocuments/Events/Event-2491/Presentation-10116/... · Team Coaching Model. 12/8/2014 11 ... Connecting

12/8/2014

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clinicalmicrosystem.org

M8:The Micro/Meso/Macrosystem

Improvement

The BIG ROOM!

Institute for Healthcare Improvement

26th Annual National Forum

Orlando, Florida

December 8, 2014

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Pre-work Assignments

• “Flipped classroom” approach

• Didactic content and case studies ahead of session

• More time for discussion and application in session

• Facilitates “active learning” format

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Pre-work Assignments

Readings

• “Improving the Flow of Older People” (Health

Foundation)

• “The Comprehensive Breast Care Program at DHMC”

(Dartmouth)

Videos• Swedish Rheumatoid Arthritis Program Feed Forward Data

• Dartmouth Institute Microsystem Academy Measurement Mini-Modules

� Balanced Measures

� Variation & Run Charts

� How to use the Excel Run Chart Template

P3


Welcome!

8:30 Welcome & Introductions

- How will we work together today?

- What you can expect to take home

- What did you bring for data?

8:45 Review/highlights of the prework

9:00 Leading Improvement

- Technocratic/Socio-cultural

- The “People” of improvement

9:30 The 5Ps with a focus on populations

- Diagnostic/procedure groups

- Subpopulations

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Agenda10:00 Break

10:15 Creating 5P Data Walls

- Lo Tech

- Hi Tech

11:00 Value Stream Mapping

Noon Lunch

1:00 The Big Room with Tom Downes

1:30 Organizing & Prioritizing with Driver Diagrams

M3 levels

1:50 PDSA/Measurement/Feed forward, feedback and

Cascading

2:45 Break

3:00 Linking leadership and coaching

3:30 Summary, questions, individual help

4:00 Adjourn

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Your Faculty Today

• Marjorie M. Godfrey, PhD, MS, BSN, FAAN

• Steve Harrison, BSc MA

• Brant Oliver, PhD, MS, MPH, APRN-BC

• Special appearance

– Tom Downes, MD, MPH

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Introductions

• Rapid fire!

– Name, role and organization

– What data did you bring?

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Pre-work Check-in

• Have you completed the pre-work?

• Have you brought data, a case study, and/or

questions from your own work?

P8

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To Develop a Change Culture““““Profound Knowledge””””

Paul Batalden

After Deming

Professional knowledge

- Professional knowledge

- Personal skills- Values, ethics

Improvement knowledge

- System- Variation- Psychology- Knowledge

Improvement in processes and systems in health care

Improving diagnosis, treatment, care, rehabilitation and follow-up

+

Increased Value for the Patients

Better Outcomes

Improved Workplace

Better System Performance


Quality Improvement

The combined and unceasing efforts of everyone – health care professionals, patients

and their families, researchers, payers, planners, educators – to make changes that will

lead to better patient outcome, better system performance, and better professional

development.

“What is “quality improvement” and how can it transform healthcare?” Qual Saf Health Care. 2007 February; 16(1): 2–3

Paul B Batalden and Frank Davidoff10

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Sustainable Efforts in Real Settings Require Inextricable Linkages…

Better systemperformance

(quality, safety, value)

Better professionaldevelopment

(competence, pride, joy)

Everyone

Better outcomepatient, population( illness burden)

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Linking Knowledge to Improvement

“Generalizable Scientific Knowledge” +

“ParticularContext”

“Measured Performance

Improvement”

• control for context

• generalize across

contexts

• sample design

I

• understand system

“particularities”

• learn structures,

processes, patternsII

• balanced outcome

measures

III

• certainty of cause & effect

• shared importance

• loose-tight coupling

• simple-complicated-complex

IV

• strategy

• operations

• peopleV

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clinicalmicrosystem.org“Every system is perfectly designed to

get the results it gets.”

Paul B. Batalden, MD

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Which system is the unit of practice, intervention, measurement, policy?

Self-care

system

Individual

care-giver

& patient

system

Microsystem

Mesosystem

Macrosystem

Market /

Geopolitical

system

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High Performing Clinical Microsystems

Information

&

Information

Technology

Staff• Staff focus

• Education &

Training

• Interdependence

of care team

Patients• Patient Focus

• Community &

Market Focus

Performance• Performance

results

• Process

improvement

Leadership• Leadership

• Organizational

support


Definition

A health care clinical microsystem can be defined as the

combination of a small group of people who work together on a

regular basis—or as needed—to provide care and the individuals

who receive that care (who can also be recognized as members of

a discrete subpopulation of patients.)

It has clinical and business aims, linked processes, a shared

information environment and produces services and care which

can be measured as performance outcomes. These systems

evolve over time and are (often) embedded in larger

systems/organizations.

As any living adaptive system, the microsystem must: (1) do the

work, (2) meet staff needs, (3) maintain themselves as a clinical

unit.

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Moving Beyond Projects and Workshops

• No single initiative or set of unaligned projects will likely be enough to produce system-level results. Even aligned projects alone will not be sufficient.

• It will be necessary to have a pervasive understanding of work as a collection of processes.

• The responsibility of managers and supervisors includes continual improvement of work processes under their control AND creating conditions for success.

• We can no longer tolerate sending staff to workshops and meetings to have them return to a work setting where there is no encouragement or support of the individual to practice what they have learned.


Leading Improvement

• Leadership matters

• Do all leaders understand how to lead quality

and improvement?

• How do they learn?

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Health Care Improvement…

• Despite an enormous variety of improvement

programs implemented to improve health care,

inconsistencies and gaps between desired and actual

health care improvement exist.

• Small improvement teams are often faced with

daily on-the-job crises and organizational inertia

that impacts the team’s ability to follow through on

well intended improvements and goals.

• Improvement knowledge and skills alone does not

achieve sustainable change. Local context can help

or hinder (including leaders).

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Leaders Can Help by…

• Helping cultivate improvement capability by designing structures, processes and outcomes of their organizational systems to support health care improvement activities

• Developing the improvement knowledge of every staff member in the microsystem to know their operational processes and system to promote action learning in their daily work

• Setting clear improvement expectations of all staff

• Providing TIME to learn and practice improvement

• Supporting improvement actions and learning using a Team Coaching Model

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Connecting

Teams, Coaching and LeadershipLeadershipTeams & Coaches

Expectations

5Ps/performa

nce

Anticipate &

assist with

data

Regular

meetings-

Provide

time &

space

PDSARapid

Tests of

change

with

measures

SustainInspire,

Know &

Tell

Stories


Leadership Survey

1. I demonstrate a commitment to QI

2. I ensure people (populations) are included in

QI

3. I encourage input on issues related to safety

and redesign of systems

4. In ensure that opportunities for QI training

and education are provided for staff and

providers

5. I set clear expectations for participation in QI

by staff and providers22

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Leadership Survey

6. I ensure that adequate resources are

available to support QI efforts.

7. I ensure that adequate time is available to

plan for QI efforts

8. I ensure that adequate time is available to

conduct QI efforts

9. I ensure barriers to QI are addressed

10. I provide an appropriate level of oversight

concerning QI efforts

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Leadership Survey

11.I participate in QI as a team member/leader

12.I communicate about QI efforts and results

across our unit and organization

13.I ensure QI activities are linked to

organizational strategic goals

14. I expect individuals to use registries and data

in their improvement work

15.I demonstrate knowledge of QI in teaching,

coaching and questions I ask

16.I promote teamwork through teaching,

coaching, team participation 24

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Leadership Survey

17.I participate in national improvement

committees and networks

18.I publish QI

19.I serve as a journal reviewer

20.I present QI in our organization

21.I present QI nationally/internationally

22. Describe when you were your best leading

QI

23.List your interests to improve

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Leadership Survey

• Leadership Teams

– Consistent communication about QI and

expectations

– Participation in improvement conversations and

actions

– Coherent and paired leadership team

– We celebrate accomplishments and offer praise

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People

Improvement strategies and execution can over emphasize the technical/mechanical/measurement aspects of improvement….

Our health care systems are not machinery with replaceable humanoid parts; they are inseparably connected with the people who operate within the system.

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Milk Chocolate

All American: you love baseball, mom, and apple pie

� A cheerleader for programs; level-headed; a good PR person and a great fund-raiser

� Kind and thoughtful; you always remember everyone's

birthday � Playful � Nurturing and interested in helping others shine

� Dependable and loyal � The kind others turn to for help

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Krackel

Creative and optimistic; you always see the cup as half full

� Messy (desk or office), but organized; you eventually find

a missing item or believe you will

� Hands-on

� A little off-beat, funny, friendly, and out-going

� Always willing to help

� Appreciative of the surprising things in life — the

"crackle" � Happiest in situations that allow flexibility, change, and

growth

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Mr. GoodbarAnalytical and logical; you can analyze things to death

• Prone to gather data before giving an opinion

• Good at playing the devil's advocate at meetings

• Likely to see all the possibilities in a situation and drive others crazy by sharing all the "what if's"

• Not a fan of deadlines; you put off starting project and could be called a procrastinator

• Fond of being an expert, but work in your own timeframe

• Most comfortable when there are rules that everyone follows: you like structure, and hate surprises

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Special Dark

Patient and thoughtful; an individualist and a problem starter

• Prone to seeing a project through from start to finish

• A good grant writer

• Insightful and reflective; you work well with difficult people

• Not patient with incompetent people or liars

• Likely to set high standards for yourself and others

• Dependable, resourceful and loyal

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Clinical Microsystems

• We all have more experience living in,

working in, and using them; than we have

studying, changing, and coaching them

• Improvement efforts are more likely to be

successful with deep understanding of the

CONTEXT.

• We use a structure of the 5Ps

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Insights to Guide Action


Highlights

• “Broken windows” theory-mapping crime

and focussing resources on the “hot spots.”

• Tabulated ED visits and mapped where

victims lived

• Assign shifts based on crime stats

• Flow in and out of hospitals

– Ambulance pick ups of falls (one hospital sent most people with serious falls)

• Block-by-block maps• “If he could find the people whose use of medical care was the highest-he

could do something to help them and lower health costs.”

• “Introduce me to your worst-of-the-worse patients.”

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Patients

Professionals

Processes

Patterns

Purpose The 5Ps


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Clinical Microsystem ImprovementWorkbooks

Patients…Assess, Diagnose & Treat

Microsystems…Assess, Diagnose & Treat

Tools for 5P Assessment

Assessing Your Practice

www.clinicalmicrosystem.org CLICK Resources

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Improving Microsystems

It’s just like patient care

• To improve a patient’s health status … a clinician assesses, diagnoses, treats, and follows-up based on biomedical science, patient preferences, and their outcomes.

• To improve a micro system’s “health” status … an interdisciplinary group assesses, diagnoses, treats, and follow-ups based on improvement science and performance feedback.


Global Aim

12

3

5 P Assessment

Theme

Global Aim

Change Ideas

Specific Aim

Measures

SDSA

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Quality by Design, 2007

Dartmouth Microsystem Improvement Curriculum

38

Process Mapping

Cause and Effect

Diagram

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KNOW YOUR PURPOSE

• Have you EVER discussed with your interdisciplinary team WHY

your microsystem exists?

• What is the purpose of your microsystem that everyone

understands and supports?

• Why do people come to work?

• What brings meaning to their daily work?

• Create a purpose statement“To promise and deliver reliable, patient-centered, evidence based care for every patient, every time”. IDCOP Berwick 2001

The purpose of our microsystem is to provide high quality care in an

environment that promotes patient and employee satisfaction.

Team Couper, MPHC


The 5Ps: Purpose

• “Money incentives do not create energy for

change. The energy comes from connection

to meaningful goals.”- Ann-Charlott Norman

Doctoral Student Jönköping University

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Avoid the “de facto” Purpose

• What leaders pay attention to matters to staff and consequently staff pay attention to that too.

• Shared purpose can easily be displaced by a “de facto” purpose:

• Hitting a target

• Reducing costs

• Reducing length of stay

• Eliminating waste

• Completing activities with in a timescale

• Complying with an inspective regime


• If purpose isn’t explicit and shared in the

group, it is very easy for “something else” to

become a “de facto” purpose in the minds of

the microsystem.

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“The last era of management was about how

much performance we could extract from

people…

The next is about how much humanity we

can inspire”

What inspires you in your microsystem? What is the microsystem aspirations? Why do you exist?

What is your purpose?


Know Your Patient Population

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Age Distribution

0.30%

31%

44.40%

24.20%

0%

10%

20%

30%

40%

50%

15-19 20-44 45-64 65- 80+

Age in Years

Per

centa

ge

Diabetes HgA1c

Number of Patients = 450

31.30%

15.80%

9.50%

9%

34.40%

0% 10% 20% 30% 40%

<7.0

7.1-8

8.1-9

>9.1

None

HgA

1c V

alu

e

Percentage

26.4% - 46.3%

0% - 12.6%

5.3% - 17.1%

11.1% - 22.9%

24.4% - 35.5%


# with

DM

# with

A1c <7%

% A1c

Control

Number

Needed to

Reach

(48.5%)

Clinic A 403 185 45.9% 11

Clinic B 204 92 45.1% 7

Clinic C 335 150 44.8% 13

Clinic D 383 158 41.3% 28

Clinic E314 129 41.1% 24

Clinic F 359 147 40.9% 28

Using Registries to Gain Knowledge of Population

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Know Your Professionals

C. Know Your Professionals: Create a comprehensive picture of your practice. Who does what and when? Is the right person doing the

right activity? Are roles being optimized? Are all roles who contribute to the patient experience listed? What hours are you open for business? How many and what is the duration of your appointment types? How many exam rooms do you currently have? What is the morale of your staff?

Current Staff

FTEs Days/Hours

3rd

Next Available

Cycle Time

Do you offer any of the following? Check all that apply.

New F/U OR Minor Range Group Visit

MD Total M T W TH F S E-mail

Web site

RN Clinics

Phone Follow-up

Phone Care Management

NP/PAs Total Registries

Protocols/Guidelines

# Exam Rooms ________

RNs Total # Minor Rooms ________

Supporting diagnostic Depts. (e.g. respiratory, lab, cardio.)

LPNs Total

LNA/MAs Total

Appt. Type

Duration Comment

New Pt

Follow-up

Others Total Minor

Staff Satisfaction Scores %

Secretaries Total How stressful is the practice? % Not Satisfied

Do you use Float Pool? ____ Yes ____ No

Do you use On-Call? ____ Yes ____ No

Would you recommend it as a good place to work?

% Strongly Agree

*Each staff member should complete the Personal Skills Assessment and “The Activity Survey”, pgs 11-13


Activity Surveys

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Professionals • Creating a joyful work environment starts with a basic understanding of staff perceptions of the practice. All staff members

should complete this survey. Use a tally sheet to summarize results.

• Often you can distribute this survey to any professional who spends time in your practice. Set a deadline of one week and designate a place for the survey to be dropped off. You may have an organization-wide survey in place that you can use to replace this survey, but be sure it is CURRENT data, not months old, and that you are able to capture the data from all professionals specific to the Primary Care Practice workplace.

Primary Care Team Satisfaction Survey

1. I am treated with respect every day by everyone that works in this practice.

�� Strongly Agree �� Agree �� Disagree �� Strongly Disagree

2. I am given everything I need—tools, equipment, and encouragement—to make my work meaningful to my life.


3. When I do good work, someone in this practice notices that I did it.


4. How stressful would you say it is to work in this practice?

�� Very stressful �� Somewhat stressful �� A little stressful �� Not stressful

5. How easy is it to ask anyone a question about the way we care for patients?

�� Very easy �� Easy �� Difficult �� Very difficult

6. How would you rate other people’s morale and their attitudes about working here?

�� Excellent �� Very Good �� Good �� Fair �� Poor

7. This practice is a better place to work than it was 12 months ago.


8. I would recommend this practice as a great place to work.


9. What would make this practice better for patients?

10. What would make this practice better for those who work here?

©2003, Trustees of Dartmouth College, Nelson

Are people happy?


Know Your Processes –Process Mapping High Level

Measures:

Baseline Cycle Time

60 minutes

15 min appt.

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Process Knowledge: Visit Cycle Time

15 Patients

Per Month Use

Clipboard

Randomly Selected

AM and PM

Average 60 minutes

For a 15 min Appt

Average 60 minutes

For a 15 min Appt


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Know Your Patterns

E. Know Your Patterns: What patterns are present but not acknowledged in your microsystem? What is the leadership and social pattern?

How often does the microsystem meet to discuss patient care? Are patients and families involved? What are your results and outcomes? • What have you successfully changed? • Does every member of the practice meet

regularly as a team? • What are you most proud of?

• How frequently?

• Do the members of the practice regularly review and discuss safety and reliability issues? • What is your financial picture?

• What is the most significant pattern of variation? *Complete “Metrics that Matter”, pg 22


Huddle Sheet • What can we proactively anticipate and plan for in our work day/week? At the beginning of the day, hold a review

of the day, review of the coming week and review of the next week. Frequency of daily review is dependent on the

situation, but a mid-day review is also helpful.

• This worksheet can be modified to add more detail to the content and purpose of the huddles.

Huddle Sheet

Practice: Date:

Aim: Enable the practice to proactively anticipate and plan actions based on patient need and available resources, and contingency planning.

Follow-ups from Yesterday

“Heads up” for Today: (include special patient needs, sick calls, staff flexibility, contingency plans)

Meetings:

Review of Tomorrow and Proactive Planning

Meetings:

Weekly Team Improvement Meetings

Daily Huddles

Monthly Staff Meetings - Improvement Agenda

Annual Retreats

Involving Patients

Patterns

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Know Your Patterns: Clinical Outcomes

CareSouth Carolina

50 patients


Completed 5Ps

Methodist Children’’’’s Hospital

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5757

Patients

Professionals

Processes

Patterns

Purpose The 5Ps


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Patient Experience in the CBP:

The Typical Patient’s Journey

Breast

Care

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Patient

Values and

Treatment

Choice

Survival rates

Recurrence rates

Decision Making Leaning toward : Mastectomy and reconstruction

Sure about choice : Unsure

Understands :

Uninformed Choice

Inconsistent with Values

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0 5 10 15 20

High Patient/Physician Ratio

No Central Figure

"Just a Number"

Lack of Patient Education

Surgical Delays

Oncology Dept.

Staffing Problems

No Clear Plan of Care

Physician Attrition

Inadequate MD-MD Communication

Lack of Coordination

Focus Groups Complaints

Number of Times the Issue was Mentioned

Lunch

12:00-13:00

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Create the Future State

• Use Lean Principles and 4 Rules for

Design to design an improved flow and

process based on the waste you have

identified.

• Lean Principles◦ Do work on time

◦ Identify problems before it’s too late

◦ Eliminate waste

◦ Reduce reproduction

◦ Irregular workload with mixed model processing

4 Rules for Design1. All work must be highly specified as to content,

sequence, timing, location and expected outcome

2. Every customer-supplier connection must be highly specified, direct, and there must be an unambiguous yes-or-no way to send requests and receive responses

3. The pathway for every product and service must be predefined, highly specified, simple, and direct with no loops or forking

4. Any improvement must be made in accordance with the scientific method, under the guidance of a teacher, at

the lowest possible level toward the ideals.

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Future Design

• What are the customer requirements?

• Where and how will you trigger or

sequence work?

• How will you make work flow smoothly?

(Reduce interruptions due to handoffs,

delays, queue or rework?

• How will work progress, delays and

problems be evident? What will you

measure? Who will measure?

• What process improvements are

necessary?

Global Aim

12

3

5 P Assessment

Theme

Global Aim

Change Ideas

Specific Aim

Measures

SDSA

P

DS

A

P

DS

A

P

DS

A

PDSA

1

3

2

Quality by Design, 2007

Learning One-by-One

68

Process Mapping

Cause and Effect

Diagram

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69

Driver Diagram Worksheet

Global Aim –

Improve nutrition

related

outpatient clinic

process

Specific aim –increase to 100% no

of patients who see dietician at every visit

by August 2014

Specific aim –increase to 100% no of patients who have a written plan/target

by Nov 2014

Specific aim –

increase to 100% annual nutrition

screening

PDSA

1

PDSA

2

PDSA

3

PDSA

4

PDSA

5

PDSA

6

PDSA

7

PDSA

8

PDSA

9

Windsor

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Kanter

While the literature often portrays an organization’s quest for change like a brisk march along a well-marked path.

Those in the middle of change are more likely to describetheir journey as a laborious crawl towards an elusive, flickering goal, with many wrong turns and missed opportunities along the way.

Only rarely does an organization know exactlywhere it’s going, or how it should get there.

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A M Tomolo, R H

Lawrence, D C Aron. A

case study of

translating ACGME

practice-based learning

and improvement

requirements into

reality: systems quality

improvement projects

as the key component

to a comprehensive

curriculum. Qual Saf

Health Care

2009;18:217-224

Gantt chart improvement work

Name of

Activity,Theme, Aim,

Test of Change

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Specific aim – increase to

100% no of patients who

see dietician at every visit

by 1st August 2014

PDSA 1 - design &

proforma

PDSA 2 - New dietietic

schedule

PDSA 3 etc

Name of


Test of Change

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31



have a written plan/target

by Nov 2014

PDSA 1 - Test Piloting

written plan

PDSA 2 - Test plan in all

clinics

PDSA 3 - Telephone

consultations

Name of


Test of Change

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31



have a written plan/target

by Nov 2014

PDSA 2 - Test plan in all

clinics

PDSA 3 - Telephone

consultations

PDSA 4 - Add written plan

to clinic profoma

Month # 1 July

Month # 2 August

Month # 3 September

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Meta/Macro/Meso/MicrosystemMetasystem- County Council (Registries)

Macrosystem- Organizations

Mesosystem-

Pathways for subpopulations

Microsystem- Front Line

76

Microsystems …The Building BlocksThat Come Together To Form

Mesosystems & Macrosystems

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77

DHMC’s Challenge: Micro, Meso, Macro

AMI Evidence Base

BA C FED

AMI Quality Metrics

1 2 3 4 5 6

Qm1 + Qm2 + Qm3 + Qm4 = QHS

©2005, Trustees of Dartmouth College, Nelson, January

IOM - Chasm

NQF - Metrics

IHI – 100K

Local Competition

Pay for Performance

JCAHO, CMS, NCQA

IHI – Whole System Metrics

1-N

T1

1-NT2

ED CATH CCU 4-East

Mesosystem

Microsystem

Macrosystem

Frontline

Nursing

Units

Nursing

Divisions

Nursing

Services

Example

The Organization from the View of the Microsystem

Source: Henriks, Bojestig, Jonkoping CC Sweden

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Clinical Microsystem Awareness and Transformational Development

Micro-Meso-Macro FrameworkMicrosystems Developmental & Organization Transformation Journey: The Stages

1. Create awareness of flow of work and our clinical unit as an interdependent group of people with capacity to make change

2. Test some changes to address some of the “embarrassing stuff”

3. See ourselves as a system of care 4. Respond to strategic challenges and invitations

5. Measure performance 6. Learn to integrate multiple improvement cycles while taking care of patients

7. Unending curiosity about and pursuit of “best known” world class processes and outcomes.

Microsystem Level“Inside Out”

Mesosystem Level“Creating the Conditions”

Macrosystem Level“Outside In”

0-6 Months *Pre-work: www.clinicalmicrosystem.org/Read Part

1, 8, 9 of series/Wa tch Batalden streaming video

• Form Interdisciplinary Lead Team (Patients/Families)

• Dartmouth Microsystem Improvement Curriculum

• Learning to work together utilizing effective

meeting skills

• Rehearsing within s tudio course format

• Practicing in clinical practice

• Daily huddles , weekly Lead Team meetings,

monthly all staff meetings

• Learning s essions (Monthly)

• Conference c alls (Between sessions)

• Link strategy, operations and people - “Make it Happen”

• Support and facilitate meso/microsystems protected time to reflect & learn

• Identify resources to support meso -micro development

including information technology and performance measure

resources

• Develop measures of microsystem performance

• Address roadblocks and barriers to micro/meso

improvements and progress

• Set goals/expectations

• Develop clear vision and mission for meso/microsystems

• Set goals for improvement

• Design meso/microsystem manager & leadership professional development strategy

• Engage Board of Trustees with improvement strategies

• Expect all Senior leaders to be familiar an d involved with

meso/microsystem improvement

• Provide regular feedback and encouragement to

meso/microsystem level staff

6-12 Months

• Staff reinforcement by Leadership

• Colleague reinforcement

• New habit developme nt through repetition

• Improvement s cience in action

• Add more improvement cycles

• Build measurement into practice

• Measures/Dashboards /Data Walls

• Playbooks & Storyboards

• Relationships between microsystems (Linkages)

• PDSA-SDSA Improvement

• Best Practice using Value Stream Mapping/ LEAN design principles

• Convene meso/microsystems to work on linkages and

“handoffs”

• Facilitate system coordination

• Link with electronic medical r ecords

• Link Business initiatives/Strategic plan to microsystem level

• Attract cooperation across health professional discrepancy

traditions

• Track & tell stories about improvement results and lessons

learned at meso/micro levels

• Schedule rounds regularly at the microsystem level

• Include improvement as regular agenda item

• Expect improvement science & measured results from

meso/microsystems

• Develop whole system measures & targets/goals

• Attract cooperation across health professional discrepancy

traditions

• Design Review & Accountability quarterly meetings for Senior Leaders

• Track & tell stories about improvement results and lessons

learned a t meso/micro levels

• Develop budgets to support and develop strategic

improvement

• Ensure resources to support meso/microsystem (e.g. IT)

• Plan time in schedule to round at meso/microsystem levels to observe improvements and progress

12-18 Months

• Continue “new way of providing care, continuously improving and working together”

• Active ly engage more staff involvement

• Multiple improvements occurring

• Network with other m icrosystems to support

efforts

• Coach network and development

• Leadership development

• Annual review, reflect, and plan retreats

• Quarterly system review & accountability

meetings to Meso -Macro Leadership

• Link performance management to daily work and results

• Support and coach microsystem leadership development

• Provide resources to support micros ystem development

• Provide feedback and encouragement to microsystem

• Encourage and support search of “best practice”

• Develop professional development strategies across all professionals

• Design HR selection and orientation process linked to identified needs of macro/mi crosystems

• Consider incentive programs for reaching target/goals

• Create system to link measurement & accountability at micro/meso/macro level

• Develop “Quality College” for ongoing support and

capability building throughout organization

© 2008, Trustees of Dartmouth College, Godfrey, Nelson,

Batalden

Some Questions For Senior Leaders to Consider At All Levels

Macrosystem leader 1. How does this work bring help / value to the

patients? What stories illustrate that? 2. What are the values that are part of the everyday

work? 3. What helps people grow, develop and become

better professionals here? 4. What helps people personally engage the never

ending safeguarding and improving of patient care?

5. What connects this whole place—from the patient and those working directly with the patient down to the leaders of the organization?

6. What helps the processes of inquiry, learning and change within, between and across microsystems and mesosystems?

7. What helps people do their own work and improve patient outcomes—year after year?

8. What might be possible? What are some of the current limits we face?

9. What are some of the most relevant external forces for this micro-meso-macrosystem?

10. Do you have the measurements & feedback necessary to make it easy for you to monitor and improve the quality of your performance?

11. Are you treated with dignity and respect everyday by everyone you encounter, without any regard for hierarchy?

12. Are you given the opportunity and tools that you need to make a contribution that gives meaning to your life?

13. Does someone notice when you’ve done the job you do?

14. As you think about what you do and your ability to change it—what gains have been made, as you think about now in comparison with the past?

15. How do you actually do what you do? What changes have you been able to make? What changes are you working on now? 16. What changes that you’ve tried haven’t worked?

17. Do people feel compelled to regularly justify or rationalize things that happen around here?

Mesosystem leader

• How do the “organization’s messages” move? • How does the “macro” strategy connect to the

microsystems? What helps adapt, respond to it?

• What are the microsystems doing about • Muda—wasted activity • Mura—irregular work flow • Muri—stress, overwork • How do the microsystems link strategy,

operations and people needed for successful execution?

• What are the helpful cultural supports for measurably improving the quality, reliability and value of care in the microsystem(s)?

• What are the cultural changes required to measurably improve the quality, reliability and value of care at the frontlines?

• What is the process for identifying, orienting the microsystem leaders…for helping set their expectations…for reviewing their performance and for holding the clinical microsystem accountable for its performance?

• What about my own style of work speaks more convincingly than my words about the desired “way” of work?

• What helps maintain a steadfast focus on “improved patient care outcomes by more reliable and more efficient systems that are regularly reflected on and redesigned?”

Microsystem leader

• How does this microsystem work? Who does what to whom? What technology is part of what you regularly do?

• What is the main or core process of the way work gets done here? How does it vary?

• What are some of the limitations you encounter as you try to do what you do for patients?

• When you want to change the clinical care because of some new knowledge, how does that work?

• What are the helpful measures you regularly use here? How are those measures analyzed and displayed?

• What are the things people honor as “traditions” around here? If you had to single out a few things that really contribute to and “mark” the identity of this clinical microsystem, what might you point to?

• What do people ask questions about around here? Who asks? Who gets asked?

• What does it take to make things happen around here? When did it work well? Who did what?

• How does information & information technology get integrated into the daily work and new initiatives around here?

• When you add new people here, how do you go about it?

• How are things “noticed” around here?

• If you to point to an example of “respect” amongst yourselves here, what might you point to?

• How do the leaders get involved in change here?

• How are patients brought into the daily workings and improvement of the clinical microsystem?

• Do people have a good idea of each others’ work? How is that brought about?

• Do you discuss the common patterns of the way you work? And the ways you test changes in them?

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Coaching Improvementwithout Leadership

is like “Sisyphus rolling a boulder up a hill..”

Coaching and Leadership

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42

The Experienced Imbalance

83

Mechanistic/T

echnocratic

Focus

Socio-Cultural

Personal

Experiences

“Humanistic”

Where is leadership in the different levels of an organization? How are they

cultivating the conditions for success?

Complexity of Health Care Improvement

“Generalizable Scientific Knowledge” +

“ParticularContext”

“Measured Performance

Improvement”

• control for context• generalize across contexts• sample design

I

• understand system “particularities”• learn structures, processes, patterns

II

• balanced outcome measures

III

• certainty of cause & effect• shared importance• loose-tight coupling• simple-complicated-complex

IV

• strategy• operations• people

V

How do I find &

believe?

What process should I

use to get “everyone”

interested and explore

differences?

This seems overwhelming!

I have so much to do..

Where do I begin?

How can we

move to

“ownership” and

provide and

improve care?

Where do we get

“ideas?”

What do

we measure and how?

Team Coaching

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43

Could Coaching Be A Missing Link?

• The gap between desired and actual quality of health care continues to exist despite years of efforts to improve outcomes.◦ Improvement methodology might explain the differences and may not

get to the root cause of reinforcement of basic improvement skills and knowledge within the context of the workplace.

• Small improvement teams are often faced with daily on-the-job crises and organizational inertia that impacts the team’s ability to follow through on well intended improvements and goals.

• Coaching, which has been used in a variety of fields, may represent an opportunity to address the need for helping interdisciplinary health care improvement teams in their own context within and between structured learning sessions. 85

Coaching ”Evoking Excellence in Others”

Flaherty

”The only way to coach effectively is to enter into a reciprocal relationship where ’coach’ and ’coachee’engage in a dance of mutual influence and growth”

Peter Senge, MIT and Society for Organizational Learning

… is not telling people what to do; it is giving them a chance to

examine what they are doing in the light of their intentions.

86

The Coaching Model: HELPING

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44

“…direct interaction with a team intended to help members make coordinated and task-appropriate use of their collective resources in accomplishing the team’s work.”

Hackman & WagemanA Theory of Team Coaching

Academy of Management Review, 2005

Team Coaching

Reported Supportive Coaching Experience

88

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Team Coaching ModelPre-Phase

Getting Ready“Meeting them where they are”

Action PhaseArt & Science of Coaching

Transition PhaseReflection, Celebration &

Renew

*Context

-Review of past

improvement efforts

and lessons learned-

tools used

-Preliminary system

review-

Micro/Meso/Macro

*Site Visit

-Resources (Data)

-Logistics (Time)

*Expectations

Clarity of aim

Leadership & Team

discussions about

roles and logistics

*Relationships

-Helping

-Keep on track

*Communication

-Virtual

-Face-to-Face

-Available & accessible

-Timely

*Encouragement

*Clarifying

- Improvement Knowledge

-Expectations

*Feedback

*Reframing

- Different perspectives

- Possibility

-Group dynamics-new skills

*Improvement Technical Skills

- Teaching

Reflection on

improvement journey

-What to keep doing

or not do again

-Review measured

results and gains

-Assess team

capability, coaching

needs & create

coaching transition

plan

Celebration!

Renew and re-

energize for next

improvement focus

Evaluate coaching 8989

Godfrey, MM et al. (2013)

Research

1. Pre/post improvement confidence

coaches in training & teams

◦ 6 and 12 months-”response shifts”

2. Improvement outcomes

◦ Performance improvement

◦ Registry/leading/lagging

◦ Satisfaction

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46

Focus Groups-Around the world participants

“Volatile” health care environment

Frontline staff are struggling

QI coaching can have a positive impact

“Feel like they have some control over

this constantly changing environment”

-Organizational leaders have significant

external pressures (reimbursement/

quotas)

“Swaying in the breeze of the current

QI fad”

Leaders

• Looking for quick fixes..

• Aim to meet some forced obligation or just

“check the boxes”

• When leadership understands what true

QI is and how to enable the support the

teams as well as the coaches…”then you

can achieve success.”

• QI should start small and then grow

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Leadership should..

• Leaders should be include in the

microsystem work from the beginning

• Teams, coaches and leaders all have to

come together at the same point in shared

understanding and commitment to be

really successful.

• ROI…sometimes improved staff morale

and empowerment of the frontline teams in

having authority to change.

• Having QI force on the frontline staff is a

“recipe for failure.”

Coaching Programs

1. 5 month Team coaching eCTC

◦ Spring and Fall (structure & process)

◦ Must have a team to practice with

◦ Subgroup coaching

2. 6 month “From Tools to Relationships”

◦ Individual work

◦ Proactive conflict management, effective communication, negotiation, emotion regulation

3. Customized coaching programs

4. Microsystem Coaching Academy-Sheffield

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Summary of the Day

• Cultivating improvement at the frontline of

care

• Balance of:

◦ Leadership and coaching

◦ Mechanistic/technocratic improvement (tools and measurement)

◦ Measures…feed forward/feedback/cascading

◦ People (getting everyone in involved

◦ Everyone learns and practices improvement

• 5Ps, value stream mapping, role optimization

◦ Microsystem, Mesosystem (create communities)

Final Questions/Clarifications

• Do you have a new perspective to lead

improvement?

◦ Examples

◦ Tools

◦ Ideas

◦ Additional needs?

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www.clinicalmicrosystem.org97

Thank you for learning with us! We look forward to hearing about your continued journey…