Leadership is a Team Affair:Experience of Building Nurse Leaders and Impact on

Quality of Care

Cherilyn Ashlock DNP, RN, NE-BC

Johns Hopkins All Children’s Hospital,

St. Petersburg, Florida

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• Building a common mission

• Building a collaborative team

• Adopting shared principles

• Adopting shared practices

• Accountability for sustainability

Our Journey to Excellence…a

Journey that Never Truly Ends

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No one discipline can do the work of

healthcare alone• yet we train independently,

• we meet independently,

• we conduct business independently

• and we wonder why?

The one thing we all have in common

THE PATIENT

Building a Common Mission

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Building a culture of excellence depends on a

multidisciplinary approach with a focus on two

equally important goals:

• Meeting the needs of the patient

• Meeting the needs of the people taking care

of the patient

Building a Common Mission

Meeting the Needs of the Patient-

Safety is the KeyStone

Safety

Performance Excellence

From the Patient’s & Family Perspective

1. Keep me safe

2. Heal me

3. Be nice to me

...in this order…

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• Evidence-based bundles

• Registries

• National collaboratives

– Children’s Hospitals Solutions for Patient

Safety

• Culture

• Team member-wellbeing

• Safety II

Key Initiatives and the Evolution of

Patient Safety

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• People first

– Physical and psychological safety

– Physical and emotional health

– Managing demands of work

– Resilience, joy and meaning

• Healthy work environment

• Resilient organization

• Environment that we can thrive in

The Team- Meeting the needs of the

people taking care of the patient

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• People greatly desire to be part of a winning team doing

meaningful work in an environment of trust.

• People desire to use their gifts, talents, and abilities to

produce great outcomes.

• Most people, when given clear expectations, exceed

them.

• Most frequently, the people closest to the work have the

most practical and possible solutions-they are just

waiting to be engaged.

Meeting the needs of the people

taking care of the patient-core

beliefs

Encourage & Empower

• Lead from any seat- but most importantly LEAD FROM THE SEAT YOU ARE IN

• Encouragement vs. empowerment– Encouragement – give confidence and support to

– Empowerment – giving (or taking) autonomy, authority to make decisions and to own the work

• Self-empowerment and empowering others

Proceed until apprehended.

Florence Nightingale

Culture and Safety

The shared values and beliefs of the individuals in the organization

(the way we act when no one is looking)

Behaviors

Culture

Outcomes

• The concept of high reliability

• The principles of high reliability

Adopting Shared Principles

High reliability organizations (HROs)“operate under very trying conditions all the time

and yet manage to have fewer

than their fair share of accidents.”Managing the Unexpected (Weick & Sutcliffe)

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• Preoccupation with failure

• Reluctance to simplify

• Sensitivity to operations

• Deference to expertise

• Commitment to resilience

Weick & Sutcliffe, 2001

Chassin & Loeb, 2013

High Reliability Principles

Anticipation/

Prevention

Containment/

Resilience

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• Always learning

• Harm free vs error free

• Transparency

• Improvements sustain when focused

attention changes

Weick & Sutcliffe, 2001

HRO – Other Features

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• Safety as a core value

– Commitment to zero harm

• Trust, respect and inclusion

• Blame-free environment

• Collaboration

– 200% accountability

• Communication

– Speaking up for safety

– Questioning and welcoming questioning

Culture of Safety – Key feature of

HRO

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• Focus on event reporting as a learning tool

• Encourage (and recognize) reporting of

events and near miss events

• Close the loop on events

– Including with staff who reported/submitted

• Tell the stories

– Impact of reporting

Reporting Culture

Changing Behaviors

Set Expectations

Educate & Build Skill

Reinforce & Build

Accountability

© 2006 Healthcare Performance Improvement, LLC. ALL RIGHTS RESERVED.

• Reinforce & Build Accountability• Leadership Rounds

• Organizational Safety Check-In

• Use 5:1 Feedback

• Find & Fix Problems

• Unit Safety Huddles

• Top Ten Problem List With Problem Owners & Action

Plans

Adopting Shared Practices: Leadership

Methods for Performance Excellence

Reinforce &Build AccountabilityFor Compliance With Performance Expectations

“Attention is the currency of Leadership.”

Leadership Rounds

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• Walk the talk

– Demonstrate safety as a core value by how

time is spent

• Learn about safety concerns and act

to/provide support for resolution

• Identify what is working

• Opportunity for relationship building,

recognition, support, feedback

• 200% accountability for leadership

methods and error prevention tools

Leadership Rounds

Catch People Doing the Right Thing!

5:1 Feedback Ratio

(5 Positive:1 Negative)

5:1 Feedback

5 positive bits of feedback for every

1 bit of corrective feedback

Why It Works:• Positive is a more powerful influencer in managing resistance

and building habits

• Builds a relationship of trust and respect between employees and supervisors and among coworkers

• Enables individuals to more effectively give and receive corrective reinforcement for a behavior that needs to be changed

Not Giving Corrective Feedback

You are contributing to their failure

You are contributing to potential harm to patients or staff…..

• Timely

• Specific

• Situation, Behavior, Impact Model• Speak the error prevention language• For constructive/corrective feedback

• Lightest touch possible to achieve the desired results

• Private• Supportive

Feedback Tips

Daily Check-In:

Safety Check-in

Unit Safety Huddles

• Proactive and reactive

• Transparent

• Sensitive to operations – what’s

happening at the point of care and how do

we support?

• Shared mental model, shared problem

solving, shared accountability

Safety Check-in

Daily Safety Check-in• Happens every day• 15 minutes • Face-to-face or by phone• Led by senior leader• Every leader comes

prepared• Problems are assigned

owners

Unit Huddles• Happens every day or

twice daily for 24-7 areas

• 15 minutes • Face-to-face on unit• Led by unit leader• Staff come prepared• Problems are assigned

owners

The Details

Find & FixSystem ProblemsThat Make It Difficult for People to Perform Effectively

Top 10 Problem List

Top 10 Problem List

The Top 10 Problem List is a management method for:

• Shared awareness of issues

• Especially issues that compromise safety

• Focus attention and effort on solving problems and

problem causes to prevent recurrence

• When a problem is resolved, a new problem is

added so there are always ten on the Top 10

Top 10 List: Need Action Plans

1. Actions map to root causes of the problem

2. Single-person responsibility for action items

3. Timelines for completion

4. Keep stakeholders informed

In Conclusion

FY 18: Journey to Zero Harm

CLABSI

• 30% reduction

• 12 fewer children harmed

Severe IV infiltrate

• 31% reduction

• 11 fewer children harmed

CAUTI

• 67% reduction

• 2 fewer children harmed

VPS SSI

• 67% reduction

• 2 fewer children harmed

Severe pressure injury

• 11% reduction

• 1 fewer child harmed

Why this matters to JHACH

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What will you

Stop?

Start?

Continue?

Change?

Reflect & Plan- Accountability and

Sustainability Starts with YOU

Questions, Sharing…..

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• American Association of Critical Care Nurses. (2016). AACN Standards for

Establishing and Sustaining Healthy Work Environments: A Journey to Excellence

(2nd edition).www.aacn.org.

• Chassin, MR., Loeb, JM. (2013). High-Reliability Health Care: Getting There from

Here. The Millbank Quarterly, 91(3), 459-490.

• HPI Press Ganey. http://www.pressganey.com/solutions/safety.

• Makary, MA., Daniel., M. (2016). Medical Error – The Third Leading Cause of Death

in the US. British Medical Journal, 353, i2139.

• Weick, KE., Sutcliffe, KM. (2001). Managing the Unexpected: Assuring High

Performance in an Age of Complexity. San Francisco: Jossey-Bass.

References