Leadership Community Workgroup Results

James B. Conway, MS, Senior Vice President, IHI
Sue Gullo, Director, IHI
Barbara Balik, Senior Faculty, IHI

Creating an Excellent Patient Experience: No longer an option
Donald Berwick’s recent article in Health Affairs "What ‘Patient-Centeredness' Should Mean: Confessions Of An Extremist" emphasizes the importance of treating patient-centeredness as it’s own unique dimension of health care quality.

Partnering with patients and family isn’t simple work but we must move from performing random acts of kindness for patients to implementing a well-designed system. Courtesy is only going to get us to “good” ratings from patients and there is evidence that creating partnerships with patients accelerates the rate of improvements that can be made. Resources are available on the IHI website to aid workgroups with patient and family centered care (PFCC) activities. An interesting finding is that leading performers on patient and family centered care could not separate patient experience from safety and clinical care. Additionally, it may be impossible to get great results without partnering with patients and families themselves to hold focus groups and or construct advisory councils.

How do we educate patients and families upon bringing them into a workgroup or advisory committee? A learning lab at the December National Quality forum will be conducted on patient and family advocacy and how to provide individuals with resources for implementing these programs. Overall, storytelling is a very meaningful, simple method of gathering patient experiences and enhancing communication, a centerpiece of any patient-family centered care programming.

Hospital Leadership and Quality Assessment Tool (HLQAT)
IHI has been very involved with the development of the Hospital Leadership and Quality Assessment Tool (HLQAT) to measure safety priorities rather than productivity measures that tap primarily into RBRVUs. Various health systems have volunteered to come together to participate in 3-month workgroups as part of the evaluation process of the HLQAT.

HLQAT assesses a mix of executives, board members and clinical leadership at both senior and middle levels of the organization. Twelve domains, which can be mapped against the IHI Improvement Map, were surveyed to ascertain specific metrics for a variety of leadership activities. Ultimately, the tool is being developed as an accessible online tool to provide hospitals with comparative data for use in their commitment to quality and safety.

"A great organization is an unsatisfied organization!"

The Keystone Initiative

Engage, Educate, Execute, and Evaluate
Sam R. Watson, Senior Vice President Patient Safety and Quality
Michigan Health & Hospital Association

We haven’t come as far as we think we have in terms of making healthcare improvements. It’s no secret that we are still faced with the human error challenges that contribute to patient safety breaches.

Sam Watson, Senior VP of Patient Safety and Quality at the Michigan Health and Hospital Association asks us, how do we reduce the complexity of healthcare delivery? This mission, tied to increasing reliability of interventions and behaviors, is also a component of an organization’s culture of safety. Since Keystone is a small team, it partners with experts to package interventions and bundles. For the MHA, patients are the keystones. Despite the technical nature of healthcare delivery, the fact that patient safety and quality are not competitive performance indicators currently inhibits the adaption of evidence into practice.

Watson warns us not to get lost in the tools, such as LEAN, Six Sigma, or other evidence-based trends. The fact that healthcare is a human system puts patients at risk every day. MHA initiatives approaches safety as a science in which the organizational culture is evaluated prior and subsequent to implementing educational forums, collaborative relationships, and transparent procedures. An assessment of the teamwork climate across MHA hospitals reveals that RN perception of teamwork climate is significantly lower than the physician perspective, and the RN perception is inversely related to turnover rates.

The Improvement Map

Reliable Routes to Exceptional Hospital Care
James B. Conway, MS, Senior Vice President, Institute for Healthcare Improvement
Sue Gullo, Director, Institute for Healthcare Improvement

The improvement map tool is available to all users of IHI.org and can provide different levels of support to participating hospitals.

There is frequently disconnect among healthcare leaders regarding the importance of perinatal care and OB admissions are often the largest ER admissions. Bridging the gap between executive and frontline decisions is a common theme throughout the improvement map processes and approaches. The Improvement Map has the capacity to engage people in IHI in short-term projects with achievable results.

The map will help hospitals improve patient care by focusing on a set of process improvements critical to achieving highest performance levels in the areas that matter most to patients. It involves structure, process and outcomes aspects of reducing harm, mortality, cost per case, and improving patient satisfaction and equity. The three main initiatives on the improvement map are: patient care, cross-cutting support and leadership management. Users can select the purpose that they would like to focus on and then the tool will highlight the processes needed to make sense of the many complex and competing demands

We must view leadership as a process opposed to an office or title. There are twelve processes of leadership that fall into the following larger processes of:

1. Set Direction and Aims
2. Build Will for Improvement
3. Generate Ideas
4. Execute Change
5. Establish the Foundation for Improvement

Governance, executive leadership and clinical leadership must come together to break new grounds and achieve transformational change.

The future of IMPACT: Day Two

James B. Conway, MS, Senior Vice President,
Institute for Healthcare Improvement

Some of the most striking events occurring in the healthcare industry are among our own organizations. Stories posted to the blogs and healthcare magazines enhance the ability of the healthcare system to move the policy agenda forward but our goal should be to get good news stories to the attention of the greater media -- we have to make sure the nation knows how we are breaking new grounds! We need to get the right news in the media to allow the public to ask questions to drive public policy. Fortunately, patient safety may finally be getting high enough on the healthcare reform agenda to make it into the conversations in Washington.

There seems to be a lot of optimism in this “transitional period” during which the focus of the nation is on financial security. We can be confident that we will need policy redesign in the near future in order to move forward with changing the healthcare system. Everything that we can do to make our work Leaner, safer, and making the patient a major player will be useful; we no longer have the luxury to leave cost containment out of the values that our organizations focus upon.

There remains a huge opportunity in the US for the general public to be involved in this debate. Jim Conway suggests that perhaps we could get involved with the writers of television shows to get the storylines of patient safety risks on the agenda. WIHI was recently launched to provide weekly stories about how different organizations are collaborating to improve care and enhance dialogue on many relevant topics.

Despite possessing complicated internal businesses, our organizations need to have the capability to connect with business customers and other clients who purchase our services. We deal with hundreds of organizations, both government and private enterprise, that are paying the bills for our services and we need to have interaction with these stakeholders.

In Massachusetts, IHI has formed a patient safety committee on health reform. The group understands the need to focus on safety across the continuum of private doctors offices, nursing homes, in home care in addition to within hospitals. Additionally, consumer will likely play a huge role in how the issue of safety emerges. The state also has an aim to answer “Do What? By When?” prior to setting up roadmaps for long term planning. This aim is directly tied to the mission of providing safe, efficient, timely, effective, equitable care.

“It’s time to not just think out of the box, but out of the building,” Berwick tells us of the importance of building up community linkages. When we’re trying to manage improvement at the hospital level it becomes critical to “connect the front office to the front line.” This is one of the biggest challenges because executive leadership must understand the work that goes on at the front line and vice versa.

Execution for Great Results

Alide L. Chase, BS, MS, Senior Vice President, Quality and Service
Kaiser Foundation Health Plan, Inc.

Care Across the Continuum Breakout Session

Jacquelyn Hunt, RPh, PharmD, MS, IHI George W. Merck Fellow,
Executive Director, Quality & Care Improvement, Providence Physician Division
Marie Schall, MA, Director, IHI
James B. Conway, MS, Senior Vice President, IHI

CNO Breakout Session

Executive Leadership: Chief Nursing Officers
Maureen Bisognano, Executive Vice President and COO, IHI
Barbara Balik, Senior Faculty, Institute for Healthcare Improvement
Karen Lee, Vice President of Nursing, Carondelet Health

The attendees, who are primarily CNOs introduced themselves, describing what they can contribute to the session and identifying their needs moving forward.

It seems that there are few safety initiatives that do not involve nursing and there is general agreement that housing the Clinical Excellence leader in the nursing department is logical since nursing is the largest workforce. The following questions were posed by attendees and really speak to the types of questions that plague senior administrators and illustrate possible IMPACT training possibilities:

• Many nursing systems are using LEAN to redesign individual hospital units but it is very resource intensive to spread the LEAN training to all areas of the hospital. How can one transfer the Toyota LEAN philosophy to the entire culture?
• How to come up with an appropriate and reasonable labor standard that’s marketable (high quality and cost efficient) when there is such a high rate of acute care patients currently?
• How to implement a system of leadership when executives have very different personalities than caregivers?
• What can we do to help middle level managers who struggle with organizational changes?
• How to document and bundle new measures that now require detailed documentation?
• Our hospital is able to successfully roll out new initiatives and see immediate change, but how can we truly sustain this improvement?

Many attendees express a desire to learn about new technical tools and gain process training, yet various virtual training tools already exist which may meet the needs of CNOs. For example, the IHI Open School utilizes WebEx technology, or radio WIHI, which produces broadcasts that involve leaders from various sites around the world. This method also allows individual sites to have a dialogue of their own around the table during the WebEx broadcast online. Courses about patient safety and quality that are offered on the Open School site are also a plausible option for nursing officers who are interested to learn more in a flexible manner.

Ginny’s Story was shown to the group as an example of a patient telling about her personal experience in a system plagued with inconsistent medical care and errors. It seems that almost every attendee present possesses a tragic story of a patient in their hospital who experienced a medical error and whose story has been listened to, documented or filmed in order to create a powerful reminder and hopefully a will for system change.

In her study, Maureen Bisognano found that the CEOs in large companies are able to manage the top 500 managers in their systems and have implemented processes to achieve high value with high performance. In this respect, regardless of different styles or settings, leadership was seen as a series of processes. Ultimately, healthcare leaders must develop the skills to become “bilingual” in order to effectively communicate with both executives and hospital staff in a language that is translatable to each.