A15 B 15 Presentation Norman - IHIapp.ihi.org/.../Document-5867/A15_B15_Presentation_Norman.pdf ·...

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Mastering Change of Healthcare Organizations: Strategic Intelligence and Profound KnowledgeDr.MichaelMaccoby,MaccobyGroupCliffordNorman,API2012IHIForumDecember11,2012

Session A15/B15This presenter has nothing

to disclose

Objectives

Recognize the root causes of disparities in quality of care

Describe the elements of profound knowledge

Integrate improvement into the plans of their organization

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What is Leadership?

Leaders are people others follow. If no one follows you, you

are not a leader. If you have followers, you are a leader.

Leadership is a relationship. Good leadership means people

willingly follow a leader who is working to further the

common good, the well-being of all stakeholders.

Good leaders make followers into collaborators.

Leadership implies a relationship that cannot be handed off to

anyone else.

Transforming Healthcare Leadership – A Systems Guide to Improve Care, Reduce Costs & Improve Population Health, Maccoby, Norman, Norman, Margolies (2013); Ch. 3

What is Management?

Management is a collection of functions; measurements, monitoring, HR,

supply functions, and the implementation of service delivery necessary for

operations.

Many management functions do not require managers since teams can

share these functions, even rotate them within a team, and some can be

automated. The job is transferable.

Both leadership and management are necessary for the success of

organizations; managers should be leaders, and in fact, most can be

developed for leadership roles. As the Institute of Medicine recommends, a

continuously learning health care system requires “broad leadership.”1

Transforming Healthcare Leadership – A Systems Guide to Improve Care, Reduce Costs& Improve Population Health, Maccoby, Norman, Norman, Margolies (2013); Ch. 3

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Types of Leaders


From Bureaucratic to Learning Organization Ideals

Bureaucratic Stability

Hierarchy/autonomy

Producing excellence

Learning OrganizationContinual improvement

Networks/independence

Creating value

Transforming Healthcare Leadership – A Systems Guide to Improve Care, Decrease Costs & Improve Population Health, Maccoby, Norman, Norman, Margolies (2013); Ch. 6

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Defining Attributes of a Learning Organization

Developed as a social system where all the parts interact to achieve the purpose of serving patients

Designing and redesigning the system of delivering care decreases per capita cost while maintaining or improving patient outcomes.

Learning from practice is widely shared and used for innovation and improvement

Partners with suppliers, client organizations and community organizations

Providers collaborate across disciplines, with patients and their families

Learning is used to inform the community, aid in the prevention of illness, and improve population health

Transforming Healthcare Leadership – A Systems Guide to Improve Care, Decrease Costs & Improve Population Health, Maccoby, Norman, Norman, Margolies (2013); Ch. 2

Strategic Intelligence, Profound Knowledge & Leadership Philosophy


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Strategic Intelligence

Foresight: Perception of the significance of events for your organization before they have occurred based on your subject matter expertise, experience, research, scanning, and ability to sense dynamic trends. Designing the Future as Visioning: Designing the future of the organization as a learning organization that can innovate and take account of the trends seen by foresight that indicate threats or opportunities for the organization.Partnering: Establishing productive relationships both internally and externally, based on mutual trust, common philosophy, and the sharing of risks and rewards.Motivating: Providing the reasons for people to follow your vision, defining motivating relationships, responsibilities, rewards, and recognition for contributions made to the organization


How do we motivate people?

1. Reasons:Why do we follow?

2. Responsibilities – in the system?

3. Relationships – important relationships?

4. Recognition – a source of dignity

5. Rewards: Which is the most powerful?Intrinsic

Extrinsic

What about the impact of personality types; how do we effectively use rewards?


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Developing a Leadership PhilosophyFour Questions

1. What is the purpose of this organization?

2. What ethical and moral reasoning determines the key decisions we make?

3. What practical values do we need to practice to achieve the purpose?

4. How do we define goals and results so they are consistent with our purpose and values?


Three Levels of Ethical and Moral Reasoning

1. The lowest level defines the good as individual well-being, avoiding punishment or gaining rewards. This implies that a person conforms to ethical rules only when an authority is watching or might subsequently learn about an infraction. With this kind of morality, there is no common good. It’s only looking out for number one.

2. The next level defines the good in terms of what a person considers good for family or organization as well as for his or herself, without concern for the effect of their actions on those outside their circle. This definition can lead to a narrow view of the common good: we vs. others. Or it can be a start of viewing self-interest in terms of the larger community that supports a group.

3. A broader definition of the common good is what benefits, or at least doesn't harm, all those who may be affected by one’s actions. This might include employees, customers, owners, communities, unborn generations and the natural environment.

At this third level of moral reasoning, leaders may be challenged to make tough decisions that don’t benefit themselves or their organizations, but will benefit the larger common good.


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Workshop: Leadership Philosophy

From your vantage point as a leader, take a few minutes and answer these four questions:1. What is the purpose of your organization?

2. What ethical and moral reasoning level determines the key decisions we make?

3. What practical values do we need to practice to achieve the purpose?

4. How do we define goals and results so they are consistent with our purpose and values?

Transforming Healthcare Leadership – A Systems Guide to Improve Care, Reduce Costs& Improve Population Health, Maccoby, Norman, Norman, Margolies (2013); Ch. 4

Cherokee Nation Health System PurposeHow do we define results?

“The Cherokee Nation Health System protects and promotes health and is the provider of choice through it’s workforce and in the

delivery of a quality experience to those we serve while practicing good stewardship

resulting in a happy and healthy Cherokee people.”


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CNHS Purpose Statement Balanced Scorecard Measures“The Cherokee Nation Health System protects and promotes health

1. Immunization Rates2. Unadjusted Raw Mortality3. Childhood Obesity 2‐18 4. Morbidity

…and is the provider of choice 5. Citizenry Satisfaction Rates6. Percentage of Third Party7. Active user Population & visits8. Percentage of patients empanelled9. Avg Panel size per team/provider‐

…through it’s workforce 10. Percent age of Workforce Cherokee 11. Staff turnover rate12. Productivity Index13. Incidence Rate Non‐Fatal occupational injuries and

illnessesand in the delivery of a quality experience to those we serve…

14. Number of cancelled appointments15. Adverse Incidents16. Third Next Available Appt 17. Equitable‐inside 14 county vs. outside 14 county

while practicing good stewardship… 18. Healthcare costs per capita19. Revenue per visit20. Cost per visit


21. Quality of life index22. Disability associated life years


Profound Knowledge

• Systems Thinking• Understanding Variation• Theory of Knowledge• Human Side of Change


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Understanding VariationWhat doctors should be reprimanded?


Theory of VariationShewhart’s Contribution

Common Causes—those causes inherent in the process (or system) over time, affect everyone working in the process, and affect all outcomes of the process

Special Causes—those causes not part of the process (or system) all the time or do not affect everyone, but arise because of specific circumstances


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Special Cause Rules


Using Measures for Judgment and Learning


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What can we predict for the target of 7.5 Unplanned Returned to the ED?


Stable or Unstable?


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Minimizing the Two Mistakes

ACTION NO CHANGE CHANGE

Take action on individual outcome; Treat as a special cause variation.

‐ $Mistake 1

+ $Correct Decision

(A)

Treat outcome as part of system; work on changing the system‐Treat as common cause variation

+ $Correct Decision

(B)

‐ $Mistake 2

MISTAKE 1: React to an outcome as if it came from a special cause, when actually it came from common causes of variation.

MISTAKE 2: Treat an outcome as if it came from common causes of variation, when actually it came from a special cause.


Using Traffic Signals on a DashboardIntegrated with the Theory of Variation

Meets Targets/Customer Specifications?Yes No

Yes

No

Ideal State Threshold State

Brink of Chaos

Chaos

Changes are being tested to impact the measure

Stab

le ?

Reference: Adopted from Wheeler’s Four States of a Process

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Purpose and 2012 System Measures

“The Cherokee Nation Health System protects and promotes health and is the provider of choice through it’s workforce and in the

delivery of a quality experience to those we serve while practicing good stewardship



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CNHS Purpose Statement Balanced Scorecard Measures“The Cherokee Nation Health System protects and promotes health

1. Immunization Rates2. Unadjusted Raw Mortality3. Childhood Obesity 2‐18 4. Morbidity

…and is the provider of choice 5. Citizenry Satisfaction Rates6. Percentage of Third Party7. Active user Population & visits8. Percentage of patients empanelled9. Avg Panel size per team/provider‐

…through it’s workforce 10. Percent age of Workforce Cherokee 11. Staff turnover rate12. Productivity Index13. Incidence Rate Non‐Fatal occupational injuries and

illnessesand in the delivery of a quality experience to those we serve…

14. Number of cancelled appointments15. Adverse Incidents16. Third Next Available Appt 17. Equitable‐inside 14 county vs. outside 14 county

while practicing good stewardship… 18. Healthcare costs per capita19. Revenue per visit20. Cost per visit


21. Quality of life index22. Disability associated life years


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Systems Thinking

Social system: a collection of interdependent processes and other elements with people working interactively guided by practical valuesto accomplish the purpose of the system.


Systems ThinkingDetail and Dynamic Complexity

Organizational Chart Systems View ‐ Nested


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Deming’s Organization Viewed as a SystemThree Types of Processes


Healthcare as a System - Conceptual View


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Ten Simple Rules for Delivery SystemsInstitute of Medicine 10 Simple Rules for Delivery SystemsCurrent Practice Improved Practice

1. Care is based primarily on visits 1. Care is based on continuous healing relationships

2. Professional autonomy drives variability 2. Care is customized according to patients’ needs and values.

3. Professionals control care 3. The patient is the source of control4. Information is a record 4. Knowledge is shared freely.5. Decision making is based on training and experience.

5. Decision making is based on evidence.

6. “Do no harm” is an individual responsibility

6. Safety is a system property

7. Secrecy is necessary. 7. Transparency is necessary.8. The system reacts to needs 8. Needs are anticipated9. Cost reduction is sought 9. Waste is continuously decreased.10. Preference is given to professional roles over the system.

10. Cooperation among clinicians is a priority.


Building the Foundation for the Learning Organization


•Purpose•Practical Values•People•Processes

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Summary

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