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

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1 2 3 4 5 6 7 8 9 10 11 12 13 14

Dela

y T

ime (

hrs

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Case 5

0

2

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1 2 3 4 5 6 7 8 9 10 11 12 13 14

Dela

y T

ime (

hrs

)

Make Change

Case 4

0

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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

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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?