Leading Quality Improvement

June 9, 2015 These presenters have nothing to disclose Leading Quality Improvement Essentials for Managers Session 9: Empower Teams to Engage in Improvement Janet Porter, PhD Kathy Duncan, RN Today s Host 2 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. 1

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WebEx Quick Reference 5 Please use chat to All Participants for questions For technology issues only, please chat to Host Raise your hand Select Chat recipient Enter Text Kathy Duncan, RN 6 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. 3

Today s Agenda Review of Session 8 Empower Teams to Engage in Improvement The Sarah Kadish Case Final Thoughts 7 Charmaine VanHeerden Thanks! 8 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 Model and demand desired behaviors - Be reluctant to simplify There is strong leadership available but not at all levels Few of us do, but once again not consistent on all levels This is an area of concern as most of the things gets blamed on incompetent nurses or too busy unit Empower necessary staff members with the needed knowledge and skills to perform their required duties regarding safety Request more participation from managerial positions to demand desired behavior and more couching of staff involved 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 4

Charmain VanHeerden Thanks! 9 Accept deference to expertise Foster mutual trust and transparency: Psychological safety Ensure open and effective communications: teamwork Provide timely response to safety issues and concerns: Fair and Just Culture For every safety problem we encounter in the unit, there is an outside Department of expertise Focusing on Just Culture but still have staff reluctant to report occurrences as they feel it is finger pointing for punishment We have in place shift Huddles, CUSP meetings, monthly unit meetings Does not always happen that we here the follow-up from reporting concerns Involve other departments of expertise for education and safety input Reinforce the No-blame culture. Cough and teach accountability even for the fact of not reporting 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 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 Janet Porter, MBA, PhD 10 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. 5

Today s Agenda Review of Session 8 Empower Teams to Engage in Improvement The Sarah Kadish Case Final Thoughts 11 Manager vs Leader 12 2010 Creative Health Care Management 6

Empower and Engage Engage Involve somebody in an activity, or become involved or take part in an activity 13 Empower To give somebody power or authority To give somebody a greater sense of confidence or self-esteem Encarta Dictionary Employee Engagement 14 Gallup, (2013). State of the American Workplace 7

15 The Impact of Employee Engagement Gallup, (2013). State of the American Workplace 16 Focused Leadership = Engagement Gallup, (2013). State of the American Workplace 8

Four Elements of Healthy Interpersonal Relationships 17 2010 Creative Health Care Management Trust 18 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. 2010 Creative Health Care Management 9

Mutual Respect 19 In environments of mutual respect people feel seen and they feel that their voices and perspectives are invited and valued. 2010 Creative Health Care Management Six Ways to Empower Your Team 20 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 10

Today s Agenda Review of Session 8 Empower Teams to Engage in Improvement The Sarah Kadish Case Final Thoughts 21 Phase I: Plan 22 What are the first things that have to happen for improvement to take place? 11

See the Problem: Reducing Wait Time at Dana-Farber 23 Measure the Problem: Process (and Wait) Time 24 12

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? 25 Connect to Mission, Strategic Plan 13

Understand Patient Flow Measure: Breast Cancer Patients Wait Time by Time of Day 28 14

Approaches to Improvement Six Sigma Define Lean Identify Value Measure Analyze Improve Understand Value Stream Eliminate Waste Establish Flow Enable Pull Control Pursue Perfection Source: The Improvement Guide, API Phase I: Plan 30 How does Sarah get started? Where to begin? 15

Understand System: processes and interactions at all levels Drivers Staff Management Leadership Governance Mainstay The Patient Entry Evaluation Therapies Transition Support Revenue Cycle HR I.T. Facilities Supply Chain Develop an Integrated Work Plan P32 IHI s framework for spread (Nolan, Schall et al. 2005) 16

Develop an Approach 33 2009 2010 2011 Phase I: PLAN Understand the problem, build a case, measure Phase II: PILOT Test the feasibility with pilot Phase III: SPREAD Spread intentionally to maximize learning Learn & Revise Learn & Revise 2015 Phase IV: SCALE Bring to scale Learn & Revise Build A Team 34 Common Goal/Purpose Defined Roles to Play Agreed Upon Rules of Engagement Performance Measures Learn Together 17

Phase II: Pilot What tools should Sarah use to design the pilot? Where should the pilot take place? 35 Piloting Results to Take to Scale Theory and Prediction Test under a variety of conditions Testing a change Make part of routine operations Developing a change Implementing a change Act Taking the Change to Full Scale Study Plan Do 18

Examples of Tools 37 Affinity Diagram Brainstorming Control Charts Fishbone Diagrams Flow Chart Gantt Chart Histogram Matrix Diagram Pareto Diagram Radar Chart Scatter Diagram Value Stream Map Fishbone Diagrams 38 19

Value Streams Picture 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 Scorecards Satisfaction Financial Quality Growth Outcome Metrics Reason For Miss A3s Process Metrics 40 20

Who and Where to Test? 41 Phase II: Pilot What can Sarah do to effectively lead a team that does not report to her? 42 21

Define Interconnected Responsibilities Do the Standard Work Surface Problems Solve those that they can Improve the Standard Work Staff Management Observe, Measure, Analyze, Action Coach the Front Line Support and Lead the Improvements Manage the Project Align to Strategy Develop the System and Structures for Support Coaching in the Work Steward the Changes Executive Performance Improvement, Decision Support, HR, I.T. Facilities Coaching vs Commanding Adaptive: Help Coachee to think for self Collaborative: Think with coachee Directive: Think for coachee Coaching Commanding Routine Urgent Emergent Engaging Collaboration Complexity Fluid Controlling Compliance Simplicity Rigid 44 22

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 46 What support systems would need to be in place for the pilot to work? 23

Phase II: Pilot 47 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) Phase III: Adoption and Spread 48 What could Sarah and the team do to persuade reluctant staff to participate in RTLS? 24

Stages of Adoption People who adopt new ideas go through these five stages! 1. Awareness 2. Persuasion 3. Decision 4. Implementation 5. Confirmation Prochaska J, Norcross J, Diclemente C. In Search of How People Change, American Psychologist, September, 1992. Phase III: Adoption and Spread 50 How might patients and families and/or PFACs be involved in designing and testing RTLS? 25

Patient Engagement Framework Specific to Patient (Individual) Specific to Disease (Dept/Unit) Specific to Quality (Organizational) General (Organizational) 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 Phase IV: Scale 52 What should Sarah do to scale RTLS throughout Dana-Farber to optimize opportunity to reduce wait time? 26

Attributes of an Idea that Facilitate Adoption Relative Advantage Simple Trialable Compatible Observable 53 Rogers, E. M. (2003). Diffusion of innovations. New York, Free Press. Rapid cycle small scale testing 54 If you want to go FAST, go SMALL Learn quickly and go BIG, FASTER 27

Phase IV: Team Longevity What should Sarah do to keep the team focused over time? 55 Sustain A Team 56 Common Goal/Purpose Defined Roles to Play Agreed Upon Rules of Engagement Performance Measures Learn Together Update Goals Recognize and Celebrate! 28

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-americanworkplace.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 58 If anything was solvable, what problem would you solve that would have the greatest impact on patient care? 29

Today s Agenda Review of Session 8 Empower Teams to Engage in Improvement The Sarah Kadish Case Final Thoughts 59 Objectives 60 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 30

Everyone in healthcare really has two jobs when they come to work every day: to do their work and to improve it. Paul Batalden, MD Senior IHI Fellow Additional Resources 62 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-advisesphysicians/ Agency for Healthcare Research and Quality (http://www.ahrq.gov/research/findings/final-reports/ptfamilyscan/index.html American Hospital Association (http://www.aha.org/advocacyissues/communicatingpts/pt-family-centered-care.shtml) Institute for Healthcare Improvement (http://www.ihi.org/offerings/initiatives/patientfamilycenteredcare/pages/default.aspx) to access the IHI Open School: http://app.ihi.org/lms/home.aspx/essentialsformanagers 31

LQI Follow-up & Communications All sessions are recorded Continuing Education credit instructions will be sent out via email Listserv address for session communications: medicationsafety@ls.ihi.org 63 LQI Post-Survey 64 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 32

Thank You from the Leading Quality Improvement Team! Dorian Burks Project Coordinator, IHI Kayla DeVincentis, CHES Project Manager, IHI Jill Duncan, RN, MS, MPH Director, IHI Kathy D. Duncan, RN Director, IHI David Munch, MD Senior Vice President and Chief Clinical Officer, Healthcare Performance Partners Janet Porter, MBA, PhD Principal, Stroudwater Associates 33