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.

CEO Breakout Session

Executive Leadership: Chief Executive Officers
Donald M. Berwick, MD, MPP, FRCP, KBE, President and CEO
Institute for Healthcare Improvement

Linking Communities and Employers to Health Care Leadership

Bruce Bradley, former Director of Health Care Strategy and Public Policy
General Motors Corporation

Bradley is one of the founders of the NQF (National Quality Forum) and a developer of the well-known HEDIS measures. As a framework for his discussion of what employers expect of the healthcare system and the providers, Bradley reminds us of the tremendous problem of medical errors that we are faced with nationally. Overall, employers expect effective and efficient healthcare delivery but they have limited options for controlling costs aside from decreasing eligibility, decreasing benefits, or improving healthcare quality by reducing waste (overuse, underuse, misuse, administrative waste, process waste).

Evolution of employers’ management of their health care programs has shifted from payment for premiums to a focus on community health. Ultimately, collective leadership at the community level powers successful and significant change, which is very difficult to achieve! (This is where IHI comes to the rescue.)

The success of GM Community Initiatives has been driven by existing local relationships that are influential in cost/quality improvements (in terms of both money and lives saved). The Greater Detroit Area Health Council spun off the Save Lives Save Dollars campaign for which the goal is to achieve 100% adherence to select evidence-based clinical guidelines and save $500 million over three years OR reduce the rate of Southeastern Michigan healthcare expenditures by 1-3%. The campaign is based on the Health Care Performance report.

Bradley calls for health plans to provide quality leadership in large corporations in order to move away from focusing on issues of attribution and toward aspects of ownership and system wide change. Basically, CEO and Board leadership is needed on every level.

In order to make collective leadership function employers must be educated on how to better support, measure, reward and hold providers accountable. Employers must also be taught to understand the business case for quality and about the potential ROI for their own time.

Panel Discussion

Critical Leadership Processes for Achieving Great Results
Nancy Schlichting, President and CEO, Henry Ford Health System
Edwin A. Ness, President and CEO, Munson Medical Center
Maureen Bisognano, Executive Vice President and COO, IHI
Frank Sardone, President and CEO, Bronson Healthcare Group
Rick Norling, President and CEO, Premier, Inc
Moderator: James B. Conway, MS, Senior Vice President, IHI

I suspect there were many “amen’s” you had in listening to the findings of Maureen and Tom’s work on Systems for Rapid and Effective Change—can you discuss a few that jumped out at you?

In response to Maureen and Tom’s work on Systems for Rapid and Effective Change, the panelists agree that site visits are an effective method for engaging leadership in the organization. Ultimately, there is a consensus that the emphasis of their study was best placed on overall leadership opposed to individual processes.

Nancy Schlichting, President and CEO of Henry Ford Health System, explains that the focus at HFHS is on strategy, structure and culture. Currently, HFHS strategies involve the execution of an immense “no harm” campaign in the quality department, launching an equity campaign to battle racial disparities in healthcare. Rick Norling, President and CEO of Premier, Inc. describes that Premier uses an explicitly defined leadership system based upon Boeing that involves documentation of high-level processes, measuring results and continuous improvement.

Transparency is getting considerable attention, and stimulating lots of anxiety. Can you speak to the role it has played in your organizational improvement journey and success?

Ed Ness, President and CEO of Munson Medical Center, describes when Munson Hospital initially tried to implement processes improvements staff denied that there were any issues occurring in their hospital. As a result, the hospital launched an “It Happens Here” campaign video and newsletter to tell the stories of people who make errors and how it impacts their lives and the lives of the patients involved. Based upon story-telling, this patient safety program was distributed to 150,000 employees and created the impetus for change in their institution. This transparency has actually created a better environment and a culture of trust.

Engaging patients and families as partners in care and improvement is considered fundamental—how is your organization responding?

The emphasis on involving patients and families in the cycle of improvement and making sure staff knows how to use that information is a common practice among the panelists. According to Frank Sardone at Bronson Healthcare Group, Bronson is making an effort to ensure everyone understands what patient and family safety really means. His health system had an event where 5,000 employees spent four hours getting a background understanding of these principles. Bronson has a Patient Advisory Council with 40+ individuals who regularly share experiences with the board and, like patients at Munson Medical Center, are highly involved with helping with the design of facilities and forms.

What have you found as the most effective strategy for spread and sustainability of results?

According to Rick Norling, CEO of Premier, Inc., without both spread and sustainability there is a risk isolating excellence into certain units. Results should be clearly identified, measured and should flow from the vision. Culture is ultimately based upon values; the importance of establishing a culture of safety is lost if the organization is missing the value of “respect”. In addition, spread has to be encouraged or rewarded as well as acknowledged.

Transparency requires accountability and accountability may instill fear in many individuals. How to get past this fear in order to use transparency and data to its fullest?

Ed: Usually problems result from systems, not individual people so the issue is to determine what went wrong/what needs to be fixed? CEO involvement may be necessary to kick-off large discussions (sentinel events, retained sponges) to thank individuals for coming together to talk about what has happened. Transparency itself is a behavior and reinforcing it is key.

Nancy: Look at leadership-maybe there is an individual leader (middle/frontline management) who doesn’t align with the culture of the organization or is not supportive with the approaches and who is holding back the progress. Case studies show that issues are not black and white; disagreement does occur and it is challenging to balance the line between accountability and transparency.

Frank: Creating a blameless culture, increasing the number of issues reported and shifting to a just culture is essential. Even with system issues it’s necessary to have accountability at the individual level and identify standards among staff at all different levels of patient care.

Maureen: Systemic variation is tolerated in healthcare more than in other industries. Sometimes fear is necessary to create a will or motivation to change and improve performance (and thus create accountability for transparency)!

How to deal with legal counsel in terms of transparency?

The panelists suggest that sometimes you must ignore legal advice to not disclose (and to essentially bury) adverse events. In fact, studies have suggested that the number of malpractice lawsuits actually decreased in the past years during which levels of transparency have burgeoned. In many hospitals, malpractice expenses are currently very low, and it is important to gather stories from interactions with patients and families to reinforce the fact that transparency is effective.

From Good to Great

How Some Have Created Systems for Rapid and Effective Change
Maureen Bisognano, Executive Vice President and COO
Institute for Healthcare Improvement

Maureen and Tom Nolan’s project stemmed from an initial examination of the volumes of information on theoretical work in the Cambridge IHI library, when it became evident that theories on leading transformational change were bottomless and overlapping. How do we identify which theories work best?

In order to get an idea of what leadership looks like when it is inspired to make continuous improvement Bisognano and her team investigated those healthcare organizations that are able to consistently make progress on multiple metrics while also reaching outcomes that are above the national average. The leaders of many of these healthcare organizations that served as case studies are present here today.

While conducting fieldwork investigations on site at Mercy Hospital, patient-centeredness appeared ubiquitous and was described as an “obsession from the Board to the front-line.” For instance, all patient rooms are private and a liberalized diet with 24-hour room service menu is offered in order to meet the patients’ needs and minimize waste. The dietician is stationed in the patient’s hall and acts as a personal consultant or coach and this has been both a cost- and nutrition-effective practice.

Upon rotation through some of the other case study hospitals, Lean practices were visibly integrated into the process design and flow throughout the organizations. Bisognano collected numerous photographs and examples of impressive systems connections, technology and multidisciplinary teams that were active during the investigation.

While disharmony on the senior team is the number one barrier to transformation, the opposite appears to be a contributor to success. In other words, the leadership systems that produce the best and fastest results include the following components:

• The executive team was cohesive and mission driven
• The strategic plan focused on quality, value, and financial stewardship
• Strong relationships existed among administration, nursing and medical staff
• Senior management invest their time to lead initiatives
• Teams were focused on the work itself, rather than the improvement methods or measures
• General dissatisfaction with performance creates motivation to change
• Standardization by use of guidelines and protocols

Maureen encourages us to identify where senior leadership teams are currently located on the spectrum of developmental changes (Discovery, Learning, Implementation, Outside Promotion), and reminds the roomful of leaders that ultimately, they set the tempo for change. Finally, sharing results is an important activity and Paul Levy’s blog is a great example of how the President and CEO of Beth Israel Deaconess Medical Center in Boston accomplishes this. The specific examples of activities conducted at various hospital systems can serve as valuable suggestions for other healthcare organizations that strive to achieve culture change.

Setting the Stage

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

The call for relentless leadership in healthcare reform is a common thread in the words of Jim Conway, Senior Vice President of IHI. Methods for constructing a leadership system for improvement are a central theme of today’s meeting. With the official bankruptcy of GM taking place in the past 24 hours, the economic downturn is imaginably at the front of the minds of the 100 leaders present. Acknowledging that this is obviously a very hard time for the Detroit community, Conway reiterates that it has held a very important role in the history of both IHI and the US. In this respect, it is difficult to disagree that the economic climate is rampant with opportunity for increased participation and engagement in leadership programs.

IHI is finding that while organizations effectively engage participants to make improvements, transparency is critical to improvements in safety. Organizations that participate in the IMPACT network are rated on their level of intended and actual participation in leadership programming. This scale ranges from .5 (intent to participate) to 5.0 (Outstanding). Conway graphically demonstrates to the group that although increases in progress have occurred, both IHI and the IMPACT community are not satisfied and will strive for sustained results.

Since leadership is a system made up of a series of processes, the emphasis in completing these aims will be on building capability. The aim is for IMPACT network leaders to achieve their well-defined and thoughtful annual aims within one year and IHI can be used for assistance accomplishing goals. IMPACT leadership will be able to access an ongoing reserve of integrated curriculum and resources and will have the opportunity to gather and collect numerous tools throughout the next two days to assist with planning for improvement.

The themes of technology, community and social change are interwoven throughout both Berwick’s and Conway’s opening remarks and have undoubtedly set the stage for the day’s events.

Welcome and Opening Remarks

Welcome and Introductions
Donald M. Berwick, MD, MPP, FRCP, KBE
President and CEO, Institute for Healthcare Improvement

Dr. Berwick welcomes the early morning crowd to the meeting in downtown Detroit and explains that although IHI is headquartered in Cambridge, MA it has deep roots in Detroit and has received endless support from the Henry Ford Health System.

The IMPACT network is central to the strategy and concept of IHI and is a vehicle to drive change. As a “spread device”, IMPACT is about coming together and sharing knowledge locally, nationally and internationally.

Four strategic pillars (and examples):
• Motivation (optimism; creating the will to change from the status quo)
• Innovation (numerous projects)
• Spread (large scale change)
• Support (IHI Open School)
• (And finally, Longevity! We must work to develop a system that will be stable and enduring.)

What’s going on in the QI realm? There is a movement to “rationalize” acute care and adopting an approach that uses “process thinking” instead of the “measures thinking” that hospitals currently follow. On average, a hospital measures over 1,000 variables, which certainly seems inefficient!

The IHI Open School is a growing network of technologically savvy health professions’ students in over 140 chapters throughout the world who are working to create their own communities for healthcare change. At the least, the use of networking to communicate (such as blogging) is a “carbon free” method that has previously lacked a business model. The surgical safety checklist sprints that were recently conducted fall into this realm. Dr. Berwick predicts that many of these new ways of relating to geopolitical entities will be critical to achieving population-based change.

The policy environment in Massachusetts is a great example of a locale where the topic of the individual insurance mandate has taken center stage; it is becoming all too clear that economic recovery will not be feasible without healthcare reform, yet conversations in Washington cannot be limited to expanding healthcare coverage.

Can we shift finances and payers in the direction of creating “accountable” healthcare organizations, Berwick asks us? Self-regulation of healthcare organizations may be key to future progress but the dilemma seems to exist within establishing an enforcement mechanism of otherwise voluntary policies. So, what will happen? Berwick outlines what he describes as a “pessimistic” short-term scenario that uses Medicaid as one vehicle for partially extending coverage. In terms of quality the obvious challenge will be to find money-saving solutions to problems.

IMPACT can have an impact and the opportunity for leadership is greater than ever!

IMPACT Leadership Meeting: June 2-3, 2009

Welcome to the Leadership for Results blog! This blog was created for our IMPACT network members who are unable to join us in Detroit and for those faculty and attendees who wish to contribute their thoughts about the program. Our aim for this blog is to highlight the sessions from the meeting and capture the ideas and feedback from our attendees while linking in those members who are not present.

During this meeting participants will be able to understand the key leadership processes that lead to great results, describe pathways that will facilitate organizational goals that lead to transformation and create excitement and interaction among peers and colleagues that will foster driving leadership for results at dramatically increased levels of performance.

So please, join us over the next few days, and as we continue on this journey after the meeting is over, and contribute in any way you would like. If you are an attendee let us know what you are learning while here in Detroit and, if you are not able to be with us, follow our blog and send in your comments.

We have planned a great program with an exciting faculty line up and hope that this blog will be valuable to you and your organization as you follow us for the next 1.5 days and beyond!