HIGH-IMPACT LEADERSHIP: DEVELOPING CORE LEADERS M12 Monday, December 5, 2016

Transcription

1 HIGH-IMPACT LEADERSHIP: DEVELOPING CORE LEADERS M12 Monday, December 5, 2016 Objectives: 1. Gain an in-depth understanding of four Core Leadership Competencies 2. Apply practical insights to developing their core leaders and teams 3. Can describe new behaviors critical to the practice of leadership in the middle 8:30-9:00 Introductions and Overview 9:00-10:15 Managing the Work 10:15-10:30 Break 10:30-12:00 Improving the Work 12:00-12:45 Lunch 12:45-2:00 Build Team Capability 2:00-2:45 Shape Team Culture Part 1 2:45-3:00 Break 3:00-3:45 Shaping Team Culture Part 2 3:45-4:00 Q&A and Building Your Plan

2 Case Study: Managing the Work at Orlando Health rev Background: In the recent months, Orlando Regional Medical Center (ORMC) began implementation and organizational spread of unit/departmental based strategy and process improvement boards called Gemba boards ( Gemba : A Japanese word meaning the actual place, used for the place where the work is done, such as an exam room, the laboratory, an operating room, or the cafeteria ( Imai, 2012, p. 62)). Each unit/department reflects the same strategic imperatives that the administration s board displays. Consequently, the administration board is a reflection of strategic imperatives that have been established by the Board of Directors and senior leadership. The difference lies in the depth of the process improvements that are reflected on each board. Any team member or leader can complete an idea ticket and submit to the boards. This case reflects one such idea, where the frontline sees the opportunity for a process improvement that could have a major impact on more than one strategic imperative. A Case for Innovation at the Middle : Chris is a Physical Therapist and the supervisor for acute care therapy. Chris heard many discussions and brainstorming sessions by his own manager and the Chief Operating Officer related to spending money to make money and how we can decrease length of stay. As part of Chris s development for further leadership roles, his manager never hesitated to encourage her team to try new things that would improve care and save money. Chris had observed multiple patient discharge delays that were due to durable medical equipment (DME) arrival times. Patients often waited hours for discharge because the outside DME Company could not deliver the required walkers, wheelchairs, or commodes until the next day. It was shown to have extended patient stays for several hours and many times overnight. Chris gathered data for two weeks, looking at the resources tied into obtaining the needed DME and the cost of the bed being utilized by a patient who was ready for discharge but was only waiting on a piece of equipment. The nurse manager for the Ortho unit worked with Chris to develop an idea ticket. It was clear that their project would require buy-in from the administration team. Chris and the nurse manager brought their ticket to the weekly administration strategy board huddle and presented their idea when it was their turn. Administration was supportive and excited at the team time. They were watching the first big process change idea come from the front line team. Chris enlisted discharge planners, nurses, and care coordinators to work with him as a team to solve the problem. Chris learned through his own research that we would not be able to obtain our own DME supplies for patients and just give it away (it costs less to give away a $32 walker than to hold a bed) due to certain laws. Chris then ventured out by calling the Center for Medicare Services (CMS) on his own. Through his discussions with CMS, he learned of a way that our organization could partner with a current vendor of orthopedic supplies and maintains certain DME at the hospital. The order for that DME would then be coordinated between the hospital and the orthopedic supply company on discharge. The outside company would then make the appropriate contacts for approval of providing certain DME and the permission to bill insurance.

3 Case Study: Managing the Work at Orlando Health rev Chris created metrics that are being used to verify the success of this new process. He measures the financial impact of the decrease in length of stay on the Ortho unit and patient experience scores specific to discharge on Ortho. While Chris and the team work toward slight modifications in the process and recording the lessons learned, the ultimate end goal will be a sustainable process that can better serve other patient populations within ORMC and other Orlando Health hospitals. Activity: - List the 5 components of Manage the Work as described by Pugh and Munch (2016). - Now, identify examples of these components in practice within this case.

4 Case Study: Orlando Health Imaging Council-Improve the Work Background: A problem was identified relative to the timeliness of approved report availability for imaging studies. This had long been a challenge in our organization and was impeding our ability to excel in areas of length of stay, throughput, patient experience and physician satisfaction. All of these impact components needed consideration as we structured a process improvement activity that would provide sustainable results. Several disciplines including imaging, transcription, nursing, IT, risk management, and physicians were identified as key stakeholders and each had a different perspective as to what the real obstacles were and why they existed. In essence, we lacked an appreciation or understanding of what each discipline was experiencing as a result of the problem and therefore, the culture was lacking with respect to collaboration, support, patience and team mindedness. We needed a means of accountability through standardization and clarity of responsibility. Ultimately, we were failing to meet the needs of our patients and our physicians. Initiative: It is relevant but not surprising that considerable change was occurring in tandem with the problem that had been identified. However, the imaging managers and supervisors recognized the need to prioritize this particular problem. To be candid, they were frustrated with the feedback that was being given regularly from other areas in terms of not having timely critical information about their patients. At the root of the problem was the need for a technology that would allow our physician to interpret studies using voice recognition and self-editing, however even with the technology we had significant hurdles with respect to old processes and policies that did not align with what we identified as our future state. We needed buy-in from all stakeholders to ensure a successful transition from the current to future state which included our physicians, technologists, administration and others. The managers recognized that the amount of change involved would require everyone on the team to understand the end goal and to understand their role in helping to achieve it. Throughout the process leadership recognized the need to evaluate processes that were impacted as a result of this change and to develop subsequent plans of action to support the overarching goal of reducing time to a final approved interpretation. The action plans were critical tools in ensuring progress. We established regular meetings with the key change agents and reviewed our progress on a regular basis. Superusers were identified by the managers and were provided the time and training necessary to be able to effectively support the in that role. The managers met with the superusers regularly and provided guidance and support. Checklists and reports were crafted that provided a means for the team to understand the progress being made ( see data provided). Physician ownership of the process was paramount but so was compliance by the imaging team of the standardized work that had been redesigned as a result of the new workflow. The reports were used to understand where and when fallouts were occurring and a weekly call was established to discuss the orders that had been entered and completed and were missing approved reports. Physician leaders were informed of compliance with the new process and were responsible for addressing individual physicians who may have been identified as non-compliant. Report out to senior leadership through the Allied Health Executive Council ensured a consistent focus on the priority and to help remove barriers that were identified by the Imaging Council as they progressed through the initiative. The team worked together to change a process that involved several disciplines, had endured significant workarounds and was outdated. The results were remarkable in that they were consistent and sustainable. Consequently, the managers identified the opportunity to further drill down to a specific area (see example slide#2). While improvement had been made overall, there was opportunity for further collaboration and focus in the emergency department where efficiency is essential. The managers continue to apply the skills they learned and refined as a result of this process and are confident in their approach for the next opportunity.

5 Data: AVERAGE MINUTES Preliminary Radiology results available in PACS within 1 hour of order: Orlando Health Process Improvement FY Feb 14' Ma r 14' Apr 14' Ma y 14' Jun 14' Jul Aug Sep Oct 14' 14' 14' 14' Ma Nov Dec Jan Feb Apr r 14" 14' 15' 15' 15' 15' Ma y 15' Jun 15' Jul Aug Sep Oct 15' 15' 15' -15 Series Data: Finalized Radiology Reports are available in PACS within 1 Hour of Order for ED Lower is Better! 60 Plain Film (DX) Examinations CY MEDIAN MINUTES Jan 16 Feb 16 Mar 16 Apr 16 May 16 Jun 16 Jul 16 Aug 16 Sept 16 APMC DPH ORMC SS

6 Activity: After reviewing the case and the above documents, the following is designed to challenge you in identifying key components of the core leader skill sets and competencies: 1. Identify examples in this case for the following: Sharing vision and building will Modeling the way Promoting transparency Encouraging mindfulness 2. Give an example of how the imaging council could use what they learned from this case to further shape team culture

7 Background: Orlando Health, established five audacious goals on its quality journey in At the beginning of the quality journey, transparency with the board, leadership and team members became a guiding principle. One system goal was to reduce overall harm by 80% within five years. Medication errors was the largest category of harm events in the organization and at each individual hospital. An interdisciplinary team was charged with studying the issues associated with medication errors in the hospitals, reviewing the literature and data and make recommendation to the Chief Quality and Transformation Officer and Vice President of Patient Care. The organization has had for many years, a well-established shared leadership model in the nursing and allied health. Engaging the team in patient safety and improvement activities became a focus. The nursing leadership council, nurse practice councils, pharmacy council were highly engaged in helping the interdisciplinary team understanding the issues with support from the quality, risk and data analytics team. Chief nursing officers from throughout the system have had, for example, a weekly call discussing all harm events as do the allied health leaders. Medication reconciliation, access to timely medications, independent double verification and distractions were some of the identified drivers associated with the medication errors. A variety of process changes occurred to make medication administration safer. The system team recommended implementation of a barcoding system for medications as an essential step to develop a safer accountable system for medication administration. The success of the implementation was critical to reduce harm events. A Case for Team Engagement Dr. P. Phillips Hospital (DPH), one of the eight hospitals in the system was the third hospital to implement the barcoding system. The goal was to achieve 90% medications barcoded. With each hospital implementation there were lessons learned and improvements made. The chief nursing officer (CNO) of DPH knew the importance of a successful implementation and created a hospital steering committee that included the nurse managers, the hospital practice chair and co-chair, the pharmacy manager, learning specialist and nursing administrators several months before the hospital was to go live. She charged the team with oversight of the process, review of the policy, resources needed, communication and engagement of the team. The steering committee was a forum for discussion, debate and decision-making. The team visited the hospital that was implementing the barcoding system observing the process and engaging with their peers. The CNO s goal was to gain an understanding the issues and challenges for the team and address safety and sustainability in her hospital. The team met weekly. Five weeks before the implementation at the hospital, the CNO asked the managers and unit practice chairs to identify equipment needed including additional computers and types of scanners based on the individual unit needs. Some units preferred wireless scanners while other requested wired scanners. Meeting with the steering team, unit practice council and allied health council, the CNO proposed a revision in the medication

8 administration policy. The proposed changes were developed to ensure that patient safety was the focus. The policy revision addressed consequences if a team member deliberately chose to not administer medications using the established barcoding system. There were two offenses that would result in immediate termination including: using and carrying printed arms bands versus using he patient s armband and creating a work-around instead of following the established process of scanning medications. All staff administering medication were required to review and sign the new policy. The unit practice council chair with the nurse manager were responsible for the implementation and conducted shift huddles. The CNO and administrators in their weekly rounding spent time with the listening to the staff on successes, issues and concerns. There was weekly messaging from the CNO, reports from pharmacy and it was a regular agenda item on the unit practice council agenda. Some staff struggled during the bar-coding system implementation. Members of the practice council, learning specialist and nurse manager coached and supported them as issues arose. After several months the percentages of medication scanned met the goal and remained stable at 90-92%. The CNO challenged the steering committee to identify ways to increase the medication scanned to 95%. The pharmacy audit identified individuals who missed more than nine medications scanned in a month. In some cases, it was issues with scanning labels on prepacked medications and IV solutions and inconsistency in policy on heparin flush scanning. Initially there was a two-page list of individuals who missed more than nine medications each. Over the course of three months, the hospital reached 95% medications scanned and remains there today. Activity: List the 4 components of Building Team Capability as described by Pugh and Munch (2016). Now, identify examples of these components in practice within this case.

9 Orlando Health: Shaping Team Culture In 2012, the critical care team at Orlando Regional Medical Center was given a survey to discover opportunities to unify the team. This included nurses, physicians, residents, respiratory therapists, pharmacists, and other key clinicians. The outcomes were telling. They painted a picture of distrust, disloyalty, leadership deficits, a lack of psychological safety, and feelings of inadequacy and lack of appreciation. Over the next 24 months, administration would team with physician leaders and departmental leaders to create initiatives centered around the patient, but that would require team cohesiveness. Team building sessions were held with team members from each area and a shared vision was created. Promises were made in terms of proper communications and how debriefings would take place after major incidents. It was not without incident or minor bumps in the road, but the outcomes have been the creation and implementation of the following patient care initiatives; These initiatives would include; Evidence-based ventilator weaning guidelines Daily collaborative rounding and checklists Weekly critical care task force meetings Early mobility protocol From 8 ICU admissions order set to 1 The team has demonstrated a positive response by the most recent team member surveys. For example, respiratory care scored the lowest at ORMC in 2013 for teamwork across departments. They felt unappreciated for their expertise and a lack of trust for the physicians. In the most recent survey, they are one of the highest scoring departments in that area. Physician leaders have been given many leadership training opportunities and as the care team leader, they are expected to set the best example for the other team members. The physicians who once had adversarial relationships with the therapists, now hold successful medical director positions. Physicians spend more time teaching and guiding the team on their decisions, rather than directing orders without explanation and input. The goals are to have a psychologically safe environment where honesty and integrity are paramount, for the sake of the patient. Activity: Give an example from this case where each competency from Shaping Team Culture is demonstrated.

10 Managing Time & Attention Exercise How do you spend your day? The following exercise is designed to collect data about how you currently spend your day. The information will help you to identify what activities add value to your patients, staff, and role and what activities do not. Instructions: For one week, track all of the activities you do during your workday. Include the start and stop time, a description of the activity, if the activity was planned or unplanned, and if the activity was value added, Incidental, or waste. The following examples and operational definitions will add you in the exercise. Current State How do you spend your time? Please use the time tracking form to capture your activity data. Here is an example of how to complete the form. Start Time End Time Activity Planned or Unplanned Value- Added/Incidenta l/waste 8:30 8:42 Read and write P Incidental 8:42 9:00 Develop A3 for improvement project P Value-added 9:00 9:15 Help staff to find medical equipment needed for care U Waste Source: A Factory of One, Fig. 1.3 Example Activities: Activities may include any of the following. The list is not all-inclusive, so add activities as appropriate. Meetings Phone Calls s Instant Messaging Moving between locations Patient Care Dialogue with staff Reviewing reports/memos Generating Fixing problems Administrative Tasks Quality Improvement reports/memos (scheduling, Payroll) Coaching Customer Communication Responding to requests Other? Planned vs. Unplanned: Planned activities are reasonably clear and are activities you planned to do as part of your daily work at a scheduled time or during the course of your workday. Unplanned are activities that presented themselves to you during your workday, but you did not predict or plan for them in advance. Work s Value: Use the following operational definitions to determine if the work activity is valueadded, incidental, or wasteful. Value-Added: Incidental: Waste: Something the customer is willing to pay for Transform the product or service in some way Done correctly the first time No-value added, but necessary No-value added, but NOT necessary Resource:

11 Managing Time & Attention Exercise Type of Waste: Using one of the categories below, select the type of waste each activity is and indicate it in the table above. Defects (Rework) Over-Production (Redundant work) Waiting Not Clear (Confusion) Transporting Stuff Inventory (Too Much) Motion (Movement of People) Excess Processing Day of the week Start Time End Time Activity Planned or Unplanned Value- Added/Incide ntal/waste If Waste, what type? Source: A Factory of One, Fig. 1.3 Resource:

12 Managing Time & Attention Exercise Summarizing Your Data Add up all the hours and determine percentages of your total time for each category. Use this as a Pareto to target opportunities improvement. Activity Category Total time (hh:mm) % of Total Time Top Three (3) Wastes From the list above, what are your top three (3) wastes? Waste Activity Description of Waste Type of Waste (see definitions below) Resource:

13 Core Leader Skills and Competencies Self-Assessment Tool How well do I? Manage the Work Low High Possible Follow-up Idea 1. Manage time and resources Create standard work and process Measure: financial, quality, customer & key processes Surface and solve problems in real time Engage across departmental/team boundaries Improve the Work Low High 6. Prioritize and align to strategy and aims

14 7. Understand current state, cause and target condition Learn and use improvement tools and methods Reduce variation and waste Get results and sustain them Build Team Capability Low High 11. Develop competency through coaching Use the whole team Communicate effectively Establish respect and accountability Shape Team Culture Low High 15. Share vision and build will Promote transparency Model the way Encourage mindfulness Keep the person at the center Page 2 of 2 Version 5.0 August 2016