Post on 01-Oct-2020
C4/D4: Leading Quality
Improvement – Strategies
and Tools for Managers
Pat Rutherford RN, MS
Vice President, IHI
This presenter has nothing to disclose.
Agenda
• Manager’s Role in Quality
Improvement
• Switch: How to Change
Things When Change Is Hard
• Strategies for Achieving Results
Objectives
After this session, participants will be able to:
• Lead quality improvement initiatives through
engagement of front-line staff
• Identify approaches that promote staff vitality
while building skills in quality improvement
• Deploy leadership strategies and tools to reach
improvement goals
MANAGER’S ROLE IN
QUALITY IMPROVEMENT
Today’s Manager
There is very little formal training in improvement science &
competing priorities often make it difficult for managers to
secure the resources & support they need.
Education
Experience
Clinical or Industry Expertise
Leadership Skills
Reputation
Management Style
Regulatory Savvy
Commitment & Compassion
Oliver Wyman Group
Traditional top down view
• Senior Managers issue directives
• Middle Managers make minor decisions and assign
tasks
• Frontline staff do what they are told
Strategy deployment hierarchy
• Senior Managers establish clear goals
• Middle Managers act as an enablers, provide coaching
and remove barriers
• Frontline staff identify problems and offer ideas for
improvement
Strengthening the Core ―While senior leadership support is crucial, middle
managers also play a vital role in safety and quality
improvement efforts. Middle managers typically have
responsibility for running a hospital department or service
area—a microsystem….middle managers act as a crucial
bridge between the two. In their role, middle managers
must translate strategic-level goals into actionable
improvement at the department or unit level, engage staff in
safety and quality improvement efforts, help determine
which care processes need to be improved and how, and
establish processes for spreading and sustaining
improvement over time.‖
“Strengthening the Core”, Frank Federico RPh and Doug Bonacum,
CSP, CPHRM, Healthcare Executive, Jan/Feb 2010
Building Manager Capability
• Knowledge of quality improvement methodologies in
order to coach teams and guide improvement efforts
• Ability to establish clear quality and safety goals for the
microsystem that are aligned with the strategic goals of
the hospital/organization
• Knowledge of measurement and resource utilization
• Ability to foster an environment characterized by a
culture of teamwork and enhanced communication
among members of the healthcare team
• Ability to teach and coach staff on the basic skills needed
to engage in improvement efforts
“Strengthening the Core”, Frank Federico RPh and Doug Bonacum,
CSP, CPHRM, Healthcare Executive, Jan/Feb 2010
Build the
skills and
capabilities
needed to
lead quality
improvement
efforts at the
middle
manager
level of an
organization
Effectively Manage
People
Effectively Manage a
Department or Team
Effectively Manage
Improvement
Manage Yourself and Your Time
Manage Down
Manage Up
Manage Peers
Build the Will for Change
Identify and Spread Good Ideas and Practices
Execute Improvement
Develop and Tend to Culture
Understand and Manage Systems
Create Effective Processes
Execute Well on Administrative Processes
Partner with Patients and Families
Sustain the Gains
The Leadership Challenge
• Model the Way
• Inspire a Shared Vision
• Challenge the Process
• Enable Others to Act
• Encourage the Heart
The Leadership Challenge
Kouzes and Posner, 2002
The Leadership Challenge
The Leadership Challenge
Kouzes and Posner, 2002
Managers’ Role in Unleashing the
Potential of Frontline Teams
To unlock a team’s abilities, a manager must spend a
significant amount of time on two activities:
1. helping the team understand the company’s
direction and its implications for team members
2. coaching for performance
Little of either occurs on the front line today. Across
industries, frontline managers spend 30 to 60 percent of
their time on administrative work and meetings. They
spend only 10 to 40 percent actually managing and
coaching frontline employees.
McKinsey & Company
Managers’ Role in Unleashing the
Potential of Frontline Teams
At ―best practice‖ companies / organizations:
• Frontline managers allocate 60-70% of their time
to the floor (at the front line), much of it in high
quality individual coaching
• These companies also empower their managers
to make decisions and act on opportunities
McKinsey & Company
SWITCH: HOW TO
CHANGE THINGS WHEN
CHANGE IS HARD
Switch: How to Change Things When Change Is Hard
Chip Heath and Dan Heath, New York: Broadway Books, 2010.
Two Parts of the Same Brain
• Emotional part
─ This part is instinctive and feels pain and pleasure
─ Location of passion
• Rational part
─ This part is reflective, conscious, deliberative and analytical
─ Tends to analyze (or over-analyze)
• These two parts are always active
─ The rational side may want to wake up at 5:45 am, allowing plenty of time to exercise
─ The emotional side may enjoy snoozing in a warm cocoon of sheets and blankets and want a few more minutes of sleep
The Elephant and the Rider
Everyone is both a Rider (rational)
and an Elephant (emotional)!
The Elephant and the Rider
• Both have strengths and weaknesses, but the
Elephant is just much, much bigger.
• The Elephant looks for immediate gratification, but
also has the energy and drive to get things done.
• The Rider has the ability to think for the long-term
and to plan for the future, but also a tendency to spin
his/her wheels – overanalyze and overthink.
• Since our emotional and rational minds compete for
control, both must be engaged to in order to create
effective change.
The Elephant and the Rider
―Perched atop the Elephant, the Rider
holds the reins and seems to be the
leader. But the Rider’s control is
precarious because the rider is so small
compared to the elephant. Anytime the
six-ton elephant and the rider disagree,
the rider is going to lose. He is
completely overmatched.‖
3-Part Framework for Change
• Direct the Rider
─Provide crystal-clear direction
• Motivate the Elephant
─Provide emotional reasons to change
• Shape the Path
─Make the change easy
─Workflows, systems, habits
The Heart of Change. John Kotter and Dan Cohen, 2002 J.P Kotter and
Deloitte Consulting LLC
Where we
want to be!
Where we are!
How do you
bridge the gap?
Hear….
Patient Stories
―Go and See…..‖
Structured Communication
Using SBAR
Situation – State why you are calling
Background – State what you are calling about (including objective data such as vital signs, labs, etc.)
Assessment – State what you think the problem is
Recommendation – State what you think
needs to be done for the patient and a
timeframe
Structured Communication
Using SBAR
S – Mr. M has sudden onset of radiating chest pain and shortness of breath.
B – He has had an AMI 5 years ago, & his vital signs are: BP186/76, HR180, RR24, O2 Sat 84%, and he is on 5Liters of O2 per nasal
A – I think Mr. M might be having an AMI
R – I need you to come evaluate the patient as soon as possible. How soon will you be here?
STRATEGIES FOR
ACHIEVING RESULTS
First Law of Improvement
Every system is perfectly designed to achieve exactly the results it gets.
New levels of performance can
only be achieved through dramatic
system-level redesign.
All
improvement
requires
change(s)…
Yet,
not all
changes
lead to
Improvement.
http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ExecutionofStrategicImprove
mentInitiativesWhitePaper.aspx
Alignment of Aims
and Strategic Initiatives
Moving Beyond Projects
―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.‖
http://www.ihi.org/knowledge/Pages/IHIWhitePapers/ExecutionofStrategic
ImprovementInitiativesWhitePaper.aspx
• Designate an Executive Leader to sponsor the QI
Initiatives and to develop a spread/dissemination
plan
• Identify opportunities for improvement and establish
aims that are consistent with the goals and strategic
priorities of the organization
• Select clinical units or program areas for the initial
front-line improvement work
• Convene Improvement Teams of stakeholders for
the initial pilot work and identify Day-to-Day
Leaders to drive the work of the front-line teams
Recommended Infrastructure
―Results‖
Achieving Desired Results
• Link unit/department aims to the hospital’s strategic
plan
• Generate New Ideas for Testing
―Snorkel‖ (adaptation of IDEO’s ―Deep Dive‖)
Adapt strategies from other Industries
Adapt ―best practices‖
Create a Learning Community (Site Visits,
Storyboard Sessions, Collaborative Learning, etc.)
• Test New Ideas and Measure Outcomes
• Implement and Spread Successful Changes
Leading Quality Improvement
©2011 Institute for Healthcare Improvement/R. Lloyd
Where we
want to be!
Where we are!
How do you
bridge the gap?
Establishing Aims:
“Start with the End in Mind”
Creating Aim Statements
• Align aims with strategic goals of the
organization
• Specify the gap to be closed
• State the aims clearly
─ what do you want to accomplish?
─ how good, by when?
• Define location or population
• Include numerical goals/targets
Aim Statement Worksheet
How good?
By when?
Clinical Unit/Department Aim Statement (What’s the problem? Why is it important? What are we going to do about it?)
―Snorkel‖….Engaging Front-line Staff
How-to Guide on Engaging Front-line Staff in Innovation and Improvement:
http://www.ihi.org/knowledge/Pages/Tools/TCABHowToGuideEngagingStaff.aspx
Learning from Other Industries
Eliminating the waste of movement…
Adapting/Adopting Best Practices
Six Changes That Save Lives
• Deploy Rapid Response Teams
• Deliver Reliable, Evidence-Based Care for
Acute Myocardial Infarction (Heart Attacks)
• Prevent Adverse Drug Events (ADEs)
• Prevent Central Line Infections
• Prevent Surgical Site Infections
• Prevent Ventilator-Associated Pneumonia
Adapting/Adopting Best Practices
Changes that Reduce Harm
• Prevent Pressure Ulcers
• Reduce Methicillin-Resistant Staphylococcus
aureus (MRSA) Infections
• Prevent Harm from High-Alert Medications
• Reduce Surgical Complications
• Deliver Reliable, Evidence-Based Care for
Congestive Heart Failure
Interventions to Advance Genuine
Partnerships with Patients/Families
IOM Rule Examples
Care is
customized
• Open visitation
• Family participation in care
• Patients establish daily goals
Patient is
source of
control
• Patients & family members activate rapid response teams
• Patient choice in meal selection
• Patient & family member participation in change of shift
report and multidisciplinary rounds
Knowledge
is shared
• Access to medical records
• Providing effective teaching and facilitating learning
Needs are
anticipated
• Conduct observations of patient experiences
• Observe peace and quiet times
Taylor, Rutherford. The Pursuit of Genuine Partnerships with patient and
family members; the challenge and opportunity for executive leaders.
Frontiers of Health Services. 2010. 26:4.
Communities of Practice
Learning Community
Matrix of Change Ideas
Difficult to Implement
Easy to Implement
Low Cost High Cost
Place concepts in matrix. Strive for
easy, low-cost solutions. Translate
high-cost solutions into low-cost
alternatives.
Improvement Project Team
• Start by focusing on one change idea
• Identify the opportunities/failures/successes in the current processes and select a process to work on
• Conduct iterative PDSA cycles (tests of change)
• Understand common failures to redesign the process to eliminate those failures
• Specify the who, what, when, where and how for the process (standard work)
• Use process measures to assess your progress over time (aim is to achieve > 90% reliability)
• Implement successful changes
Setting Aims
Establishing Measures
Selecting Changes
http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/.
hunches,
theories &
ideas
changes that result
in improvement
Testing and Implementing Changes
Plan
Study
Act
Do
Cycle 6
Cycle 8
Cycle 1
Cycle 2
Cycle 3
Cycle 4
Cycle 5
Cycle 7
Aim: The multidisciplinary plan of care is
customized to meet the patient’s daily goals
Cycle 1: One nurse elicits daily goals using script
Cycle 2: One nurse customizes the dialogue for each patient
Cycle 3: All nurses on one shift elicit daily goals
Cycles 4, 5, 6, 7….
Cycle 8: One nurse put daily goals in chart
Cycle 9: One nurse uses white boards in room to communicate
goals
Cycle 10: All nurses on one shift put goals on white boards
Cycle 11: Standardize process for identifying and
communicating goals
Cycles 12, 13, 14……
( continue testing cycles until the aim is met
Adopt ?
Adapt ?
Abandon ?
Use of Measurement for Learning
Quantitative:
• Outcome measures
• Process measures
• Diagnostics
Qualitative:
• Success stories
• Anecdotes
• Testimonials
Sequential Testing and Implementation
Sustaining the
improvement and
spreading the change
to other locations
Developing a
change
Implementing
a change
Testing a
change
Theory and
Prediction
Test under
a variety of
conditions
Make part of
routine
operations
Study
Act
Do
Act Plan
Do Study
Getting Results and Spreading
Successes
Time Order (Monthly Data)
Observed Data
Design Target
Pilot Unit #1
Pilot Unit #2
All Nursing Units
Change 1
Change 1
Change 1
Change 2
Change 2
Change 2
Why is it important
to plot data over time?
“Tracking a few key measures over time is the single most powerful tool a team can use.”
Case1
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Dela
y T
ime (
hrs
)
Make Change
Before and After Test
0
1
2
3
4
5
6
7
8
9
10
1 2
De
lay T
ime
(h
rs)
Before Change (measure on Week 4)
After Change (measure on week 11)
Change made between week 7 and week 8
Case 2
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Dela
y T
ime
(hrs
)
Case 3
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Dela
y T
ime (
hrs
)
Case 5
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Dela
y T
ime (
hrs
)
Make Change
Case 4
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Dela
y T
ime (
hrs
)
Make Change
Make Change
Case 6
0
2
4
6
8
10
12
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Dela
y T
ime (
hrs
)
Make Change
Make
Change
Evidence that change tested result in an improvement?
Quality Improvement Through Planned Experimentation
Evidence that change tested result in an improvement?