The presenter has nothing to disclose Leading for Improvement and Getting Results at SCALE Marie Schall, MA Institute for Healthcare Improvement November 10, 2015
Responsibilities of Leaders Support collaborative team Develop a plan and guide the spread or scaleup of improvement beyond the collaborative team (i.e., within and across facilities, care homes, etc.)
Improvement at Collaborative or System Level Will New possibilities RESULTS Build confidence Ideas Sequencing and tempo Execution
Discussion What have you done to actively support your collaborative team(s)? Have you begun to prepare your facility or municipality to scale-up improvement from the collaborative team to other sites? Are there other roles that leaders have played during the collaborative?
Supporting the Collaborative Team Review their aim and make the connection between their work and the goals for the municipality Set up review meetings at least monthly to discuss their monthly progress reports; remove barriers to progress Visit the site of the improvement to learn what the team is doing Promote the team s work. Talk about the importance of the team s work in internal and external meetings any opportunity that will make the work visible to others
The Scale-up Framework P6 Best Practice exists New Scale-up Idea Setup Build Scalable Unit Test Scale- Up Go to Full- Scale Leadership, communication, social networks, culture of urgency and persistence Phases of Scale-up Adoption Mechanisms Learning systems, data systems, infrastructure for scaleup, human capacity for scale-up, capability for scale-up, sustainability Support Systems
Readiness for Moving up the Sequence Topic is a strategic initiative within the organization An executive(s) is responsible for the effort A person or team will manage the day-to-day scale-up activities Pilot site(s) is relatively self-sufficient and has at least some initial evidence about the positive impact of the change, i.e., has developed the model or scalable unit
The Scale-up Framework P8 Best Practice exists New Scale-up Idea Setup Build Scalable Unit Test Scale- Up Go to Full- Scale Leadership, communication, social networks, culture of urgency and persistence Phases of Scale-up Adoption Mechanisms Learning systems, data systems, infrastructure for scaleup, human capacity for scale-up, capability for scale-up, sustainability Support Systems Where would you place yourselves today in the sequence?
What is a scalable unit? Smallest facsimile of the whole system Representative slice of the whole system Contains elements (i.e., people, processes, patients/families, and infrastructure) that are common to the system Produces a result that is representative of the whole system result (i.e., can predict system level improvement based on the scalable unit)
Purpose of Developing the Scalable Unit Generate the set of interventions (improvements) that will achieve the goal, i.e., change package Test bed the infrastructure capabilities Generate will, interest for spread
The Role of the Collaborative Team in the Framework Conducts tests that contribute to the development of the scalable unit Helps to make the case for change Makes it easier for others to do the work Develops the messengers
Leader s Role
Leaders Role Setting the agenda for change Assigning responsibility Providing resources and support Monitoring and guiding the effort Sustaining improvements
Developing an Aim for Scale-up What improvement(s) will you take to scale: Target Goals, i.e., whose lives will be different because of your effort? What impact do you expect to have? Who are the adopters, i.e., who do you need to reach: Time Frame, i.e., by when?
Creating a Municipal Leadership Team for Scale-up Provides direction for the scale-up effort; monitors progress Several areas of expertise and/or responsibility to consider for the team include: the designated municipal leader; a day-to-day leader of the scale-up effort; representatives from the pilot site(s) representatives from the target sites, including leaders from those sites and others, including facility leadership; clinical expertise; and support services such as information technology, human resources, and quality improvement.
Types of Leadership for Scale-up Executive Sponsor Senior Leaders Coaching Adopters Sense- Making Supporting Change Agent Nolan, K; Nielsen, G; Schall, M. "Developing Strategies to Spread Improvements." From Front Office to Front Line: Essential Issues for Health Care Leaders: Joint Commission on Accreditation of Healthcare Organizations, 2005, p. 62..
Role of the Executive Sponsor Coaches other leaders Supports day-to-day leader Addresses resource issues Responds to system issues Sets expectations Carries message (sense-making)
Role of the Day-to-day Leader Assists Executive Sponsor in creating spread plan Guides the execution of the spread plan Leads Spread Team Monitors outcomes and progress and shares with Executive Sponsor Communicates! Both up and down!
Creating Adoption Mechanisms Build a communication plan Identify and utilize social networks Foster a culture of urgency and persistence
Purpose of the Communication Plan Build awareness Move adopters from decision to action Support and mentor adopters
Creating a Communications Plan What audience(s) do you need to reach? What will be your message(s)? Who will deliver the message(s)? What channels of communication will you use? What story do you have to tell (from the work of the pilot teams) How will you review your communications plan and make adjustments? Cooper A; Gray J; Willson A; Lines C; McCannon J; McHardy K, Exploring the role of communications in quality improvement: A case study of the 1000 Lives Campaign in NHS Wales, Journal Of Communication in Healthcare, Volume 8, Issue 1 (March, 2015), pp. 76-84.
The WAY in Which We Communicate is Important SHARE INFORMATION SHAPE BEHAVIOUR General Publications flyers newsletters videos articles posters Personal Touch letters cards postcards Interactive Activities telephone email visits seminars learning sets modeling Public Events Road shows Fairs Conferences Exhibitions Mass mtgs Face-to-face one-to-one mentoring shadowing (C) 2001, Sarah W. Fraser (Adapted from Ashkenas, 1995)
Creating Support Structures Learning system How people will be connected to learn improvements Data systems Identify data, collection methods, method for review and accountability Infrastructure Staffing, resources, communication systems, etc. Capability for scale-up What improvement skills and training are needed Sustainability Creating reliable systems (i.e., the train tracks)
Developing a Measurement Strategy Outcome measures Rate of scale-up
Iowa Health System Aim: 50% Reduction in ADEs System-wide in 20 30% Iowa Health System Adverse Drug Events: % of Sampled Charts with Harm Levels ADEs E-I Targets: 20 = 10%, 2003 = 4% 20% % of Charts 20% 10% 14% 9% 9% '03 Target 4% 10% 6% 4% 6% Reduced Sample Size 10% 11% 6% 6% 5% 5% 3% 2% 10% 6% 3% 4% 0% N-01 D-01 J- F- M- A- M- J- J- A- S- O- N- D- J-03 F-03 M-03 A-03 M-03 J-04
Tracking the Spread of Specific Ideas (1 site) Reconciliation Culture FMEA Testing Impl. on Pilot Started Impl. on Pilot Complete Spread Planned Spread Begun Spread Widely Spread Compl Change Hazard Insulin sldng scale X 1/16/2004 Exec WalkRounds X 12/19/2003 1/16/2004 1/26/2004 2/2/2004 2/2/2004 Mar-04 Apr-04 Safety briefings X 12/19/2003 1/1/2004 2/9/2004 2/9/2004 2/9/2004 Admit form X 12/2003 2/9/2004 2/10/2004 2/9/2004 2/9/2004 Transfer Reconcilia X 4/7/2004 Adm Reconciliation X 2/22/2003 Testing Implementation Started Implementation Complete Spread Planned Spread Started Spread Widely Spread Complete
Iowa Health Progress Report to Leadership Site Exec Walks Unit Briefings HFE Briefings FMEA Reconciliation Hazard Areas 1 X X X X X Coumadin 2 X X X X X PCAs 3 X X X Plan 4 X X Plan X X 5 X X Plan Plan X 6 X X X Plan Lovenox Heparin 7 X Plan Plan X 8 X Plan X X X X = At least one unit implementing the change
Displaying the Spread of Multiple Ideas Facilities participating 10 9 8 7 6 5 4 3 2 1 0 Iowa Health System: 10 Hospitals in Iowa and Illinois System-wide Diffusion - Exec Walk Arounds Jun-01 Jul-01 Aug-01 Sep-01 Oct-01 Nov-01 LS1 Dec-01 Jan- Feb- LS2 Mar- Apr- May- Jun- Jul- Aug- Setp Oct- Nov- # IHS facilities 10 9 8 7 6 5 4 3 2 1 0 Iowa Health System: 10 Hospitals in Iowa and Illinois System-wide Diffusion - Hazard Areas - At Least 1 per facility Jun-01 Jul-01 Aug-01 Sep-01 Oct-01 Nov-01 LS1 Dec-01 Jan- Feb- LS2 Mar- Apr- May- Jun- Jul- Aug- Setp Oct- Iowa Health System: 10 Hospitals in Iowa and Illinois System-wide Diffusion - Unit Briefings System-wide Diffusion - Medication FMEA # facilities using in 1+ or more units 10 9 8 7 6 5 4 3 2 1 0 Jun-01 Jul-01 01 01 01 01 LS1 01 LS2 Jul- Setp # facilities completed FMEA Setp Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Aug- Oct- Nov- 10 9 8 7 6 5 4 3 2 1 0 Jun-01 Jul-01 Aug- 01 Sep- Oct-01 Nov- Dec- 01 01 LS1 01 Jan- Feb- Mar- LS2 Apr- May- Jun- Jul- Aug- Oct- Nov-
The Scale-up Framework P29 Best Practice exists New Scale-up Idea Setup Build Scalable Unit Test Scale- Up Go to Full- Scale Leadership, communication, social networks, culture of urgency and persistence Phases of Scale-up Adoption Mechanisms Learning systems, data systems, infrastructure for scaleup, human capacity for scale-up, capability for scale-up, sustainability Support Systems