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Engaging Leadership and Governance in Quality and Patient Safety Initiatives

April 15, 20151:00 – 2:00 p.m. CT

Kimberly McNally, MN, RN, BCCTrustee, University of Washington Medicine

Kenneth P. Anderson, DO, MS, CPECOO, Health Research & Educational Trust

2014 Silver Award Recipient

Engaging Leadership and Governance in Quality and Patient Safety

Initiatives

HPOE Live!2015 Webinar Series

Kenneth P. Anderson, DO, MS, CPE


Business Case for Improving Care

• Describe the “Reasons to Participate”–Payer rewards tie to explicit quality measures –Regulators publish specifics on performance (using the Web as an “ external driver”)

–Patients are demanding greater transparency –Defining and deploying “best practice” will define our future


The Impact of NOT Focusing

• When Quality and Patient Safety systems fail:–Patients lose trust–Reputational impact: patients tell friends and neighbors

–Patients “vote with their feet” – growth impact

–Risk management impact: it’s costly–Most important: patients may be hurt!


Themes for Quality Efforts

• Consistency – Commit to a culture of excellence for every encounter (“Flawless Execution”)

• Standardization– Automate whenever and wherever reasonable– Link operations (work flows) and physician preferences for care (best practice use)

• Teamwork– Interdisciplinary teams (including IT) promote greater efficiency and effectiveness


Questions: Roles and Responsibilities

• Who is responsible for quality and patient safety in our health care environment?

• How do we promote the critical thinking needed to improve?

• How does your personal mission align with the privilege of “caring” for our community?


Roles of Leadership

• Empower front‐line staff• Provide resources• Clearly state the vision• Stimulate and guide• Model behaviors• Reward and recognize


Setting a Culture of Quality

• Effective Systems Are:– Transparent– Intentionally designed

– Continuously improving

– Participant‐based– Holistic

• Systems Based Approach– Team‐based Solutions– Data driven– Measure‐rich– “Systematized”– Well‐communicated


Start With Key Quality Principles

• High Value Care Principles (IOM):– Safe– Timely– Effective– Efficient– Equitable–Patient Centered


Structure: Four Corners of Quality

• Quality Control– Accreditation, compliance, safety, risk

• Performance Excellence (Process)– Operations‐focused, standardization of care

• Quality Development (People)– Tools acquisition and leadership training

• Quality Innovation (Technology)– Delicate interface with technology as an enabler


Quality Control – The Regulatory Base

• Accredited by the Joint Commission (TJC)• Licensed by the State (Dept. of Health)• Certified for payment by the Feds (CMS)• Regulated by numerous State and Federal agencies


Performance Excellence – Better Each Day

• Role of incremental improvement: P‐D‐C‐A cycles of improvement engine

• Advanced project planning using D‐M‐A‐I‐C• Process‐focused with impact on outcomes (Economic, Clinical, and Humanistic Outcomes)

• CORE measures as the initial point of entry (measures tied to payment updates)

• Show progress visually and simply


Outpatient Cardiac Care PlansMI & CAD (Antiplatelet/Beta Blocker) Composite Scores

81.3% 81.2%

84.6% 85.1% 85.8% 86.2%88.8%

90.9%

93.5%93.3%93.1%92.1%

88.0%

82.8%

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

100%

Aug-09 Oct-09 Dec-09 Feb-10 Apr-10 Jun-10 Aug-10

Score Goal


Quality Through People Development

• Train leaders and the Board – give them the “Keys to the Car”

• Train and equip Medical Staff leaders, provide a sustaining framework

• Focus on future leaders ‐ residency quality programs for young physicians; develop nursing quality leaders

• Use reinforcing resources such as IHI Open School Chapter establishment


Quality Innovation and Redesign

• Answers simple question: “What works?”• Hardwire effective care patterns into daily work• Mine the EMR to create “Wisdom”• Put the tools of change in the hands of the end users, and make tools easy to use

• Engage “Activated Patients” to create patient‐centered value

2014 Silver Award RecipientFirst week in September

ILI percentage by week

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1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

ILI %

of o

utpa

tient

vis

its

2007/8 % ILI2008/9 % ILI2009/10 %ILI

February


0

100

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21Week

# of Cases (a

ll ZIPs)

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# of Cases (spe

cific

ZIPs)

All ZIPs

60091‐Wilmette

60061‐Vernon Hills

60626‐Rogers Park

Jan 8 June 3

Seasonal Flu

Outpatient Influenza Like Illness


Scorecards and Dashboards

• “Measuring” is the start of “Managing”• Cascading dashboards allow direct “line of sight” communication and alignment

• “A picture is worth a thousand words” –promote effective and efficient communication

• Consider “whole system measures” to demonstrate broad themes of improvement


At A Glance Project Reporting

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2014 Silver Award Recipient21


Cutting Harm Across the Board in Half

22

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

Total H

arm/1,000

Discharges

Jan‐12 Feb‐12 Mar‐12 Apr‐12 May‐12 Jun‐12 Jul‐12 Aug‐12 Sep‐12 Oct‐12 Nov‐12 Dec‐12 Jan‐13 Feb‐13 Mar‐13 Apr‐13 May‐13 Jun‐13 Jul‐13 Aug‐13 Sep‐13 Oct‐13 Nov‐13 Dec‐13Baseline 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2 13.2

Hospital 29.4 19.3 14.4 13.8 13.6 16.7 17.2 10.9 12.5 14.7 5.3 6.8 10.1 11.4 8.9 7.3

Goal 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6 6.6

Total Harm per 1,000 Discharges

EMR Go Live

Reduction of EED’s starts

Increased Transparency of

Patient Harm Data

75% Reduction!

Patient Fall Strike Teams

Yuma, Arizona


To Change the Practice of Medicine

• Create higher “value” health care – engage ALL participants, especially physicians

• Promote patient activation/engagement• Satisfy the Triple Aim: better care for individuals AND populations at lower cost

• Standardize evidence‐based management: achieve scale, reduce cycle time, accelerate gains, deploy sustaining systems

HPOE LIVE! WEBINAR

Engaging Leadership and Governance in Quality and Patient Safety InitiativesApril 15, 2015Kimberly McNally, MN, RN, BCC

Trustee, UW Medicine Board

What is board engagement?

Board WorkBoard Work

RelationshipsRelationships

EngagementEngagement

OUTCOMES

Board engagement leads to…

Trusting relationships

Trusting relationships

Relevant work

Relevant work

Attention to detailsAttention to details

Improved governanceImproved

governance

Indicators of an engaged board• Forward-thinking group whose work and meetings are designed around critical issues

• Participate in well-designed opportunities for meaningful deliberation in an environment characterized by trust, candor and respect

• Provide challenge and support to accelerate change

• Trustees feel their time, talent and energies are well used; can articulate value produced

UW Medicine

Engagement Pyramid

Physician LeadershipPhysician

Leadership

BoardLeadership

BoardLeadership

Aligned metricsAligned metrics

ExecutiveLeadershipExecutive

Leadership

Collaborative Leadership throughPartnership between the Board, executive & physician leaders- at entity and

system level

Why is Collaborative Leadership Important?

• Health care organizations are messy, complex and interdependent

• Effective strategies require a systems approach and inclusion of multiple perspectives

• Many sectors and constituents need to “own” parts of the goals and solutions

• Leadership role is to build a community of leaders

Collaboration

Collaboration needs a different kind of leadership;

it needs leaders who can safeguard the process,

facilitate interaction and patiently deal

with high levels of frustration. Chrislip & Larson

Highlights of Our Evolution• Getting started• Transitioning forward• Advancing to future

Evolution• Creating culture of collaborative leadership

• Recognizing fiduciary responsibility extends beyond finance; trustees see their role as quality champions

• Making sense of myriad performance metrics

• Recognizing strategic importance of quality data and trends in public disclosure

• Developing quality literacy

• Benchmarking with UHC Quality Scorecard

• Challenging traditional assumptions; building will for improvement

Evolution• Setting directional focus with board self-assessment, periodic retreats; reinforce with monthly meetings

• Learning to ask better questions to understand factors underlying performance and what leaders are doing to address them

• Aligning quality metrics with executive recruitment, selection and performance

• Designing roles for entity and system boards and quality committees to ensure rigorous, proactive and effective oversight and to reduce redundancy

UW Medicine Quality Focus AreasTriple Aim

• Execute on Patient are First framework• Transform care; new delivery models• System-level quality measures and dashboards • Continue focus on reducing hospital-acquired infections

• Ongoing attention and focus on safety culture• Broaden ambulatory setting metrics• Understand population health/ACN metrics• Educate and engage next generation of clinicians

Some levers – increase engagement• Build physician leadership capacity

• Conduct benchmarking – national, regional, internal

• Use dashboards – targeted for different audiences

• “Unpack” metrics – meaning, importance, factors that impact results

• Embrace mistakes/errors

Some levers – increase engagement• Attend educational programs together

• Invest in leadership development

• Integrate patient voice/story at every opportunity; use board members to share their care experiences

• Build partnerships – board/executive/physician leaders; unit level MD/Nurse Manager dyads; across continuum

Exerting Influence• Know when to take a stand

• Intentional agenda design and skilled facilitation; create the “right” conversations

• Balance inquiry and advocacy to advance dialogue

• Reward authentic dialogue about quality/safety gaps

• Create climate for innovation

Board as conversational agentsEnvision the future - Advance the

dialogue – Shape the agenda

•How is the Board currently using conversations well?•Which conversations are missing or not effective?•What are the conversational practices?

How “good” is our hospital/health system?

Are we driving down/eliminating harm?Are we driving down/eliminating disparities?

Are we providing patient/family-centered care?Are we taking cost out of our system?

Is our workforce prepared?Are we improving the health of our population?

How do we know? What’s the evidence?

Shifting the conversation

• What patterns of data are we seeing over time?

• How is this connected to…?• What assumptions are we making?

• How else can we think about this?

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Sample questions

• How will we translate the community health needs assessment data into specific strategies? What health care disparities will we focus on reducing?

• How do we know we have the right patient and family engagement strategies for the people we serve?

• What is the front-line users experience with ____?• After we hardwire safety practices, what’s next?• How have we changed medical and nursing practice based on evidence-based research?

Sample questions• What are we learning…and how are we spreadingeffective practices for fall prevention across the system?

• With MD credentialing, how do we incorporate feedback from other clinical team members? How do we know the MD professionalism policy is making a difference?

• What evidence do we have that front-line staff feel supported to speak up?

• How are we rewarding innovation?• What’s missing from our approach to make us feel confident about our commitment to quality?

Sample questions• What have we learned from our discharge call data….where are the gaps in effective transitions?

• How have we advanced our palliative care since last year?

• If we truly aspire towards a patient/family centered culture, what can the Board do to support this work? How can we be effective sponsors?

• How does our budget reflect our commitment to employee and workplace wellness?

• How does our performance management system align with the quality goals?

Executive Safety Rounds• Observe culture and care

in action – listening and learning tours

• Understand challenges faced by front-line staff and physicians

• Demonstrate commitment to continuous improvement

• Set participation expectations

• How do you learn about quality goals?

• What aspects of the clinical environment could lead to patient harm?

• What would make the work you do safer for patients?

• What have you learned from any near misses that may occurred recently?

• What challenges do you have implementing safety protocols?

The board meeting is the center of communication &relationship success or failure. Larry Walker

Committee Meeting Tips• Develop annual work plans• Jointly prepare agenda – committee chair, executive and physician leaders

• Choose meaningful patient stories to set the tone• Provide right amount of data• Watch for jargon…ask for lay explanations• Engage in dialogue re: two key dashboard indicators that are trending red

Committee Meeting Tips• Pose questions to catalyze discussion• Encourage trustees to ask questions• Recognize leadership actions that enhance the culture of safety

• Ensure shared understanding of what was heard at the meeting, what will happen as a result, and what’s next

• Seek regular feedback on committee’s effectiveness

Lessons Learned• Have clear agreements in place to support partnership. Provide timely feedback as needed.

• Consistency is key. Everyone needs to be reporting the same data. Cascade structured communication.

• Trust, transparency and acknowledgment are essential ingredients.

• Work to balance attention to metrics with time for “blue sky” thinking.

• Focus and sophistication emerges over time. • Awareness re: fatigue with growing pace of change …still move forward in face of uncertainty.

To lead is to live dangerously because when leadership counts,

when you lead people through difficult change,

you challenge what people hold dear-their daily habits, tools, loyalties, and

ways of thinking-with nothing more to offer perhaps than a

possibility.

Ron Heifetz, Leadership on the Line

Kimberly McNally, MN, RN, BCCTrustee, UW Medicine Board

[email protected]

Thank you!

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Questions?

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Please click the link below to take our webinar evaluation. The evaluation will open in a new tab in your default browser.

https://www.surveymonkey.com/s/hpoewebinar4‐15‐15

With Hospitals in Pursuit of Excellence’s Digital and Mobile editions you can:Navigate easily throughout the issue via embedded search tools located within the top navigation bar

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Keyword search of current and past guides quickly and easily

Bookmark pages for future reference

Important topics covered in the digital and mobile editions include: Behavioral health Strategies for health care transformation

Reducing health care disparities Reducing avoidable readmissionsManaging variation in care Implementing electronic health records

Improving quality and efficiency Bundled payment and ACOsOthers

@HRETtweets

#hope #equityofcare

For a listing of upcoming HPOE webinars check out our website.

www.hpoe.org/hpoewebinars

For more information go to www.hpoe.org

Join Us!www.aha‐

slhq.org/QualityRoadmap

2015 Quality Roadmap: Achieving Equitable Care

for All Patients

Meeting Purpose

• Bring together a diverse audience from membership groups across AHA

• Focus on the intersection of quality and equity to advance patient‐centeredness, improve health outcomes and establish new paths towards success

• Hear from cutting‐edge leaders in quality and equity of care

• Network during breakout sessions and a storyboard reception

Meeting Details

• Date: Wednesday, July 22, 2015 | 9:00 a.m. –6:00 p.m. PT

• Location: San Francisco, CA | San Francisco Marriott Marquis

• Who:Members of one of the host organizations to participate

• More details here!

Call for Storyboards!

• Share your organization’s story!– Exhibit original content about your organization's work to address health care disparities, promote equity of care and improve quality of care for all patients

– Highlight ongoing or recently concluded improvement projects, best practices or case studies

– Include a performance measurement or data analysis component

• Submit your proposals electronically by Friday, May 29 at 6:00 p.m. CT

• Click here for more info.

For More Information

Email [email protected]

and visithttp://www.aha‐slhq.org/events/Roadmap/qualityroadmap.shtml

Thank You!

Contact Us:www.aha‐slhq.org

[email protected] | (773) 270‐3127@AHA_SLHQ

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