Seven Leadership Leverage Points for Organization-Level Improvement in Health

Care

Presented by:Robert L. Colones, MBA

President and Chief Executive OfficerFlorence, South Carolina

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care

A Quality Leadership Challenge

• We have become good at making improvement happen for one condition, on one unit, for a while.

• We have not learned how to get measured results, quickly, and ‘sustainably’, across many conditions for the whole organization.

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care

‘Give me a lever long enough, and I shall move the world.’ARCHIMEDES

The leverage points are offered as a sort of hypothesis …

If leaders are to bring about system-level performance improvement, they must channel attention to and take action on these points.

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care

1

Establish and

Oversee System-Level Aims for Improvement at the Highest Board and Leadership Level

1 - System-Level Aims for Improvement

Mortality Rate - MRMC

0.00%

0.50%

1.00%

1.50%

2.00%

2.50%

3.00%

3.50%

4.00%

Oct-04

Nov-04

Dec-04

J an-05

Feb-05

Mar-05

Apr-05

May-05

J un-05

J ul-05

Aug-05

Sep-05

Oct-05

Nov-05

Dec-05

J an-06

Feb-06

Mar-06

Apr-06

May-06

J un-06

J ul-06

Aug-06

Sep-06

Oct-06

Nov-06

Dec-06

J an-07

Feb-07

Mar-07

Apr-07

May-07

J un-07

J ul-07

Aug-07

MRMC Average Avg+1Std Avg-1StdAvg+2Std Avg-2Std Linear (MRMC)

1 - System-Level Aims for Improvement

Rate of Harm per 1000 Doses

MRMCNational Average 2-8 per 1000 doses

00.5

11.5

22.5

33.5

4

CY

2001

CY

2002

CY

2003

CY

2004

J an-05 Feb-05 Mar-

05

Apr-05 May-

05

J un-05 J ul-05 Aug-

05

Sep-

05

Oct-05 Nov-

05

Dec-

05

J an-06 Feb-06 Mar-

06

Apr-06 May-

06

J un-06 J ul-06 Aug-

06

Sep-

06

Oct-06 Nov-

06

Dec-

06

J an-07 Feb-07 Mar-

07

Apr-07 May-

07

J un-07

Adverse Drug Events Linear (Adverse Drug Events)

Seven Leadership Leverage Points for Organization-Level Improvement in Health Care

2

Develop an Executable Strategy to Achieve System Level Aims at Highest Level of Leadership

2 – Executable Strategy: Four Critical Steps

1 A few, focused breakthrough quality and safety aims

2 Senior Team develops a ‘rational portfolio of projects’ with scale and pace to achieve breakthrough aims

3 Key projects are resourced with leaders and infrastructure

4 Senior Team monitors and responds

2 – Executable Strategy

Reliability

Theory

Quality as a Core Value

Prioritization Physician & Executive Engagement

Change Theory

Improvement Methodology

CoreSuccess Factors

2 – Executable Strategy: Quality is a Core Value

Service

Science

Safety

“Just Culture” Executive TeamEngagement

Physician Leadership

2 – Executable Strategy: Prioritization A few, focused breakthrough quality and safety aims

Quality & Safety… Building a Strategic Advantage through

Enterprise Wide Improvement

Clinical Effectiveness

(CE)

OperationalEffectiveness(‘Lean’ or OE)

2 – Executable Strategy: CE Prioritization A few, focused breakthrough quality and safety aims

OpportunityDriven by Clinical

Data

Complications Readmissions Mortality

Cost Length of Stay

2 – Executable Strategy: CE Prioritization A few, focused breakthrough quality and safety aims

896450

340294

252244222214200194182174170162158142132126118118

Potentially Avoidable Days

The total potentially avoidable days are distributed across numerous DRGs, but 45% of days are in the top twenty DRGs.

High Opportunity DRGs: Potentially Avoidable Days

45.4%

422 2.12 DRG 106 CABG with Cath

732 0.61 DRG 116 PTCA with Stent/Pacemaker

174 1.96 DRG 107 CABG without Cath

112 2.63 DRG 144 Other Circulatory Dx

588 0.43 DRG 143 Chest Pain

82 2.98 DRG 075 Major Chest Procedures

296 0.75 DRG 209 Major Joint and Limb Procedures

132 1.63 DRG 475 Resp. System with Vent

206 0.97 DRG 174 GI Hemorrhage

114 1.69 DRG 122 Circulatory Disorder with AMI

78 2.34 DRG 493 Laparoscopic Cholecystectomy

232 0.75 DRG 121 Circulatory disorder AMI

42 4.03 DRG 385 Neonates

56 2.88 DRG 239 Path Fx and MS Malignancy

130 1.21 DRG 005 Extracanial Vascular Procedures

170 0.84 DRG 298 Nutritional and Metabolic-Peds

320 0.41 DRG 088 COPD

156 0.81 DRG 316 Renal Failures

96 1.23 DRG 026 Seizures and Headache-Peds

84 1.4 DRG 110 Major Cardiovascular Procedure

Total Days Opportunity: 10,543 days

Example

Data

2 – Executable Strategy: CE Prioritization A few, focused breakthrough quality and safety aims

DRG N Description Cost LOS Mortality Readmission Complication116 608 Other permanent pacer implants 107 335 CABG w/cath109 187 CABG w/o cath373 819 Vag Del w/o complicating Dx374 127 Vag Del w/sterilization or D&C385 62 Neonates387 32 Prematurity148 * 110 Major sm & lg bowel procedures112 172 PTCA1 * 71 Craniotomy > 17 w/o trauma125 350 Circulatory disorders w/AMI w/ CATH 124 234 Circulatory disorders w/o MI,w/ CATH 121 174 Circulatory disorders w/AMI 478 * 95 Other Vascular procedures w/CC113 55 Amputation for circulatory disorders110 * 67 Major CV procedures (AAA)120 43 Other Circulatory OR procedures430 593 Psychoses88 * 299 COPD89 289 Pneumonia127 * 481 Heart failure & shock416 74 Septicemia143 515 Chest Pain

Financial Quality

EXAMPLE

2 – Executable Strategy: OE Prioritization A few, focused breakthrough quality and safety aims

Creating Efficiency of Work: Operational Effectiveness

1. Deployment of “Lean” methodology2. Eliminate waste or non-value added work3. Make processes flow smoothly4. Involve staff in redesign of work

2 – Executable Strategy: OE Prioritization A few, focused breakthrough quality and safety aims

‘A3’Opportunity

Driven by Operational Data

Access to CareMake the WorkMore Enjoyable

Better Use ofResources

2 – Executable Strategy: OE

RIE Results from Cardiac Value Stream – Nursing Documentation Time Saved

from toPre-population of fields 60.0 minutes 12.0Electronic documentation 40.0 12.0Peds Questions 10.0 0.5ED TBA paperwork 40.0 0.0Room orientation 20.0 0.0Speech screens 10.0 3.0Diabetic bundle/flow sheet 4.4 1.4Plans of care 24.0

8.0Plus other …

Total Time Savings: Admission History, 60 minutes per

patientadmitted to 27 minutes; Plan of care, 24 minutes to 8

minutes

2 – Executable Strategy: Four Critical Steps

1 A few, focused breakthrough quality and safety aims

2 Senior Team develops a ‘rational portfolio of projects’ with scale and pace to achieve breakthrough aims

3 Key projects are resourced with leaders and infrastructure

4 Senior Team monitors and responds

2 – Executable Strategy: Key Projects Resourced with Leaders, Infrastructure

Clinical Effectiveness-Teams are Physician-Led-Work for 3 months at 2

week intervals-4 to 5 Physicians-Care Manager RN, MSN-Educator-Implementer-Multi-disciplinary Team-VP Champion

Operational Effectiveness

- Team Leader- Work for 6 to 12 months

in VSA, @ 1 RIE/month- OE Facilitator with

certification in ‘lean’- 9 members with 3 in the

area of focus, 3 up/downstream, and 3 ‘fresh eyes’

- VP Champion

2 – Executable Strategy: Key Projects Resourced with Leaders, Infrastructure

1. Establishing a Sense of Urgency2. Forming a Powerful Guiding Coalition3. Creating a Vision4. Communicating the Vision5. Empowering Others to Act on the Vision6. Planning and Creating Short-Term Wins7. Consolidating Improvements and

Producing Still More Change8. Institutionalizing New Approaches

– John Kotter, Leading Change

2 – Executable Strategy: Monitor and Respond

‘The currency of leadership is attention.’

J. Reinertsen, MD

Formal & Informal resources focus on the aims

Inside: calendars, meeting agendas, project reviews, performance feedback and compensation systems

External: Transparency

2 – Executable Strategy: Monitor and Respond

STOP START

Focus on benchmarks

Relying on technology

Thinking “tools” &

“best practices”

Delegating leadership

Focus on “Ideal” & rate of improvement

Rely on people/Process

Technology serves P&PRunning the

organization on “principles”

Leading from the front, constant reinforcement

STOP START

Dozens of metrics

Internal focus (specialty, unit,

role…)

Managing by Control

Improving what we know …greater

complexity

Few, visual, focused metrics that matter

Patient centered, Value Steam focus

Lead through Principles, Standard work.

Lead transformation …start with simple

STOP START

Experts collect data, Design/manage

projects

Incremental improvement

Top down execution Rigid command &

Control

The “fix” mentality

Access knowledge & Creativity of workforce

Double digit gains in vital areas

Bottom up execution Agile and adaptive

The “fitness” mentality