Leading Out of the Mess Michigan Primary Care Association Fall 2009 Annual Conference Roger L. Chaufournier Executive Director CSI Solutions, LLC September 2009

Objectives of the Workshop 1) Understand how to utilize a leadership Framework to drive improvement in the organization 2) Understand best practices of leadership in driving organizational change

1) Understand how to utilize a leadership Framework to drive improvement in the organization

2) Understand best practices of leadership in driving organizational change

Overview Chapel Road Case Study Framework for Leadership Leading Transformation Bringing it All Home: Next Steps

Chapel Road Case Study

Framework for Leadership

Leading Transformation

Bringing it All Home: Next Steps

CHAPEL ROAD HEALTH CENTER

Chapel Road Health Center Single site FQHC located in an urban environment Leadership turned over List of challenges to overcome What are your impressions of this organization?

Single site FQHC located in an urban environment

Leadership turned over

List of challenges to overcome

What are your impressions of this organization?

Common Leadership Practices Reactive vs. Proactive Blame the people Throw people or policies at the problem Gimmicks Slogans/campaigns New Policies/Approval Process & Signatures Reorganizations Use of extrinsic motivation (carrot and stick)

Reactive vs. Proactive

Blame the people

Throw people or policies at the problem

Gimmicks

Slogans/campaigns

New Policies/Approval Process & Signatures

Reorganizations

Use of extrinsic motivation (carrot and stick)

All Leadership Approaches Work! Autocratic-Top Down-Controlling Hands Off Team based But certain leadership principles lead to higher levels of performance ….

Autocratic-Top Down-Controlling

Hands Off

Team based

But certain leadership principles lead to higher levels of performance ….

“ Hardly a competent workman can be found who does not devote a considerable amount of time to studying just how slowly he can work and still convince his employer that he is going at a good pace. Under our system a worker is told just what he is to do and how he is to do it. Any improvement he makes upon the orders given to him is fatal to his success.” Frederick Taylor

“ We trained hard...but it seemed that every time we were beginning to form up into teams we would be reorganized. I was to learn later in life that we tend to meet any new situation by reorganizing; and what a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralization.” Who do you think said this and in what era did they live?

Peter Drucker “ Every few hundred years in the history of Western society a transformation takes place. The transformation transcends all aspects of society; the government, the schools, the values, religion, culture, etc. The transformation is not sudden, but takes place over a 50 year or more period. The transformation is so profound that the children born in that era can not comprehend the time in which their parents were born and in which their grandparents lived.”

Transformational Leadership Problem Solving: System Focused not People Focused Strategic vs. Reactionary Focus on Quality as a Business Strategy Measurement and Feedback as a driver for change Leadership as a system; continuous reflection and improvement Build organizational capacity for excellence

Problem Solving: System Focused not People Focused

Strategic vs. Reactionary

Focus on Quality as a Business Strategy

Measurement and Feedback as a driver for change

Leadership as a system; continuous reflection and improvement

Build organizational capacity for excellence

Small Group Dialogue What would you do to right the ship? What role should the Chief Medical Officer Play? If you were the CEO, what would you do? How can the CEO best work with the Medical Director to develop a game plan?

What would you do to right the ship?

What role should the Chief Medical Officer Play?

If you were the CEO, what would you do?

How can the CEO best work with the Medical Director to develop a game plan?

Baldrige Health Care Criteria for Performance Excellence Framework A Systems Perspective 4 Information and Analysis 6 Process Management 2 Strategic Planning 5 Staff Focus 1 Leadership 3 Focus on Patients, Other Customers, and Markets Organizational Profile: Environment, Relationships and Challenges Malcolm Baldrige National Quality Award 7 Organizational Results

Peter Drucker’s Effective Executive: Eight Practices They ask “what needs to be done” They ask “what is right for the enterprise” They develop action plans They take responsibility for decisions The take responsibility for communicating The focus on opportunities rather than problems They run productive meetings They think and say “we” rather than “I” Give the executive the knowledge they need Convert the knowledge into effective action Ensure that the whole organization feels responsible and accountable

They ask “what needs to be done”

They ask “what is right for the enterprise”

They develop action plans

They take responsibility for decisions

The take responsibility for communicating

The focus on opportunities rather than problems

They run productive meetings

They think and say “we” rather than “I”

PULL PUSH 1. Set Direction: Mission, Vision and Strategy 3. Build Will Plan for Transformation Set Aims/Allocate Resources Measure System Performance Provide Encouragement Make Financial Linkages Learn Subject Matter Work on the Larger System 5. Execute Change Use Model for Improvement for Design and Redesign Use Change Leadership Model Review and Guide Key Initiatives Spread Ideas Communicate results Sustain improved levels of performance Make the status quo uncomfortable Make the future attractive Leadership for Transformation 4. Generate Ideas Read and Scan Widely, Learn from other Industries/Disciplines Benchmark to Find Ideas Listen to Customers Invest in Research &Development Knowledge management Understand Organization as a System IHI 2003 2. Establish the Foundation Reframe Operating Values Build Improvement Capability Build Relationships Develop Future Leaders Personal Preparation Choose and Align the Senior Team

3. Build Will

Plan for Transformation

Set Aims/Allocate Resources

Measure System Performance

Provide Encouragement

Make Financial Linkages

Learn Subject Matter

Work on the Larger System

5. Execute Change

Use Model for Improvement for

Design and Redesign

Use Change Leadership Model

Review and Guide Key Initiatives

Spread Ideas

Communicate results

Sustain improved levels of

performance

4. Generate Ideas

Read and Scan Widely, Learn from other Industries/Disciplines

Benchmark to Find Ideas

Listen to Customers

Invest in Research &Development

Knowledge management

Understand Organization as a System

Reframe Operating Values

Build Improvement Capability

Build Relationships

Develop Future Leaders

Personal Preparation

Choose and Align the Senior Team

Leadership Build will through a clear vision people want to buy into Communicate Clear system level metrics Clear system priorities Empower staff to move the dots Align organization and remove barriers

Build will through a clear vision people want to buy into

Communicate

Clear system level metrics

Clear system priorities

Empower staff to move the dots

Align organization and remove barriers

Strategic Leadership Clear vision and mission Constant Fingerprinting of the vision Set a limited number of core strategic drivers-the vital few System of accountability

Clear vision and mission

Constant Fingerprinting of the vision

Set a limited number of core strategic drivers-the vital few

System of accountability

Quality Initiatives Must be Broad Enough and Deep Enough to Move the Big Dot Organization message : this year, patients will not acquire catheter-related bloodstream infections, surgical site infections, or ventilator-associated pneumonia IOM aim : Care should be safe JHHS-level goal : patients will not be infected as a result of being in our hospital Projects (often cross-departmental) : CABG surgical site infection initiative, ICU catheter initiative, laminectomy initiative, etc. Each absolutely MUST have clear metrics: you manage what you measure. If you don’t capture the data, develop a way JHM Strategic Priority : Clinical excellence Source: Richard Davis, Ph.D. Johns Hopkins Medicine

Organization message : this year, patients will not acquire catheter-related bloodstream infections, surgical site infections, or ventilator-associated pneumonia

Aligning Work to your Business Imperative Community Health Health Health Center Center Assessment Strategic Plan QI Plan & Monitoring System Priorities for Participation in Improvement Projects and Priorities for Spread Collaborative Team Established Plan Act Do Study Cycles Plans For Spread Based on Successful PDSA Monthly measures Improved Health Center Performance lower cost > clinical outcome >patient & staff satisfaction Update the plan

Improved

Health

Center

Performance

lower cost

> clinical

outcome

>patient &

staff

satisfaction

Information Management and Analysis Set of system level measures for the organization They focus on “moving the dots” Information is available to front line work force Data driven decision making

Set of system level measures for the organization

They focus on “moving the dots”

Information is available to front line work force

Data driven decision making

SJHS Performance Metrics Balanced High level Linked to trended run and control charts Indicator-specific comparative rates (green circle) Adds focus to “move to the outside circle” Some successes

Balanced

High level

Linked to trended run and control charts

Indicator-specific comparative rates (green circle)

Adds focus to “move to the outside circle”

Some successes

09/30/09 Dashboards Informed decisions through the use of appropriate and timely data Source: Richard Davis, Johns Hopkins Business of Medicine Program

Work Process Management Put people to work on building the better mouse trap Use change methods to drive improvement Empower staff with the tools to study and improve work Drive the improvement efforts

Put people to work on building the better mouse trap

Use change methods to drive improvement

Empower staff with the tools to study and improve work

Drive the improvement efforts

Every Leader Needs a Toolkit of Improvement Methods To Lead Change Improvement Methods: PDSA PICOS/Lean Six sigma (DMAIC) AIM Kaizen Reengineering These tools are specific to the improvement task at hand. All have similarities in approach: applying the scientific method to improvement: defining, measuring and testing

Improvement Methods:

PDSA

PICOS/Lean

Six sigma (DMAIC)

AIM

Kaizen

Reengineering

These tools are specific to the improvement task at hand.

Value Stream Mapping Phases Preparation Current State Future State Planning Agreeing on what process to study, how to map it and who will participate. Agreeing on a well understood map of the current situation. Agreeing on a shared vision of a lean future state. Agreeing on how to implement the future state vision Adapted from Lean Enterprise Institute

Standards Identified (selected examples....) 98% overall accuracy rate of registration 90% competency rate of registration staff 100% of claims include referral/auth. 95% insurance verification and precert. 90% TOS payments collected/counseled Reduce denial rate Increase patient satisfaction Standards to guide PICOS groups

98% overall accuracy rate of registration

90% competency rate of registration staff

100% of claims include referral/auth.

95% insurance verification and precert.

90% TOS payments collected/counseled

Reduce denial rate

Increase patient satisfaction

Standards to guide PICOS groups

PICOS Groups Redesign Registration Processes Key metrics for each group Vision for new processes Action items Short Term: implement immediately after workshop Long Term: implement over 12 months while group continues to meet

Key metrics for each group

Vision for new processes

Action items

Short Term: implement immediately after workshop

Long Term: implement over 12 months while group continues to meet

Revenue Recovery Accomplishments Activity Baseline FY00 FY01 FY02 FY03 FY04 FY05 (Q2) Competency Scores 65% 80% 90% 92% 91.4% 92.5% 93.5% Admin. Denial Rate 1.4% 1.4% 1.4% 1.4% 1.4% 2.0% 1.7% Clinical Denial Rate 2.3% 1.7% 2.0% 2.0% 1.8% 1.8% 1.8% TOS Collections $13.8m $17.5 $8.7m* $10.1m $8.6M $9.5M $4.4M Collection Rate 85.6% 87.4% 87.5% 88.1% 88.6% 89.3% 87.9% Days in A/R 118 96 75 61 56.3 50.6 53.7 Late Charges 9% 4% 4% 3% 2.6% 3.1% 2.5% Cumulative Revenue FY00 – FY05 = $98,000,000

Work Force Management Create an environment that breeds success Recruit great people Train and empower the work force Recognition as a driver or performance Building “Good to Great” cultures

Create an environment that breeds success

Recruit great people

Train and empower the work force

Recognition as a driver or performance

Building “Good to Great” cultures

What Leads to Intrinsic Motivation? Control over the variables Feedback The ability to make a contribution and succeed Variation Recognition Make work like a Nintendo game!

Control over the variables

Feedback

The ability to make a contribution and succeed

Variation

Recognition

Make work like a Nintendo game!

Role of Recognition The Carrot Principle Gostick and Elton 2007 200,000 employee ten year study Frequent, variable, meaningful praise tied to: Goal Setting Communication Trust Accountability

The Carrot Principle Gostick and Elton 2007

200,000 employee ten year study

Frequent, variable, meaningful praise tied to:

Goal Setting

Communication

Trust

Accountability

Recognition Formula Annual expenditures $1000 per employee or 2% of payroll Every 7 days thank for free (hand written note, verbal, email) 4-6 /year above and beyond wards ($100-$2000 $100 annually- 2 times per year event award $200 year Service Awards (90 day;1 yr;3 yr; 5yr;10yr; every five year thereafter

Annual expenditures $1000 per employee or 2% of payroll

Every 7 days thank for free (hand written note, verbal, email)

4-6 /year above and beyond wards ($100-$2000

$100 annually- 2 times per year event award

$200 year Service Awards (90 day;1 yr;3 yr; 5yr;10yr; every five year thereafter

Empowerment How do you build an empowered organization? Philosophy Delegated authority Training Monitoring Communication Reinforcement Celebration

How do you build an empowered organization?

Philosophy

Delegated authority

Training

Monitoring

Communication

Reinforcement

Celebration

BRINGING IT ALL HOME What do I do now?

What do I do now?

Bring it All Home-Key Points Leadership can be viewed as a system A framework can help you improve your leadership system Each Domain of the Framework has principles and best practices you can learn to master You should maintain a continuous learning environment

Leadership can be viewed as a system

A framework can help you improve your leadership system

Each Domain of the Framework has principles and best practices you can learn to master

You should maintain a continuous learning environment

Action Planning What three steps can you take upon return? (new concepts you want to explore) What next step do you need to do to continue your learning journey?

What three steps can you take upon return? (new concepts you want to explore)

What next step do you need to do to continue your learning journey?

Where to find more information Malcolm Baldrige National Quality Award IHI.org Monograph: The Seven Leadership Leverage Points Built to Last ; Jim Collins and Jerry Porras. First, Break All the Rules: What the World’s Greatest Mangers Do Differently , Marcus Buckingham and Curt Coffman The Leadership Challenge , James Kouzes and Barry Posner The Carrot Principle Gostick and Elton 2007

Malcolm Baldrige National Quality Award

IHI.org Monograph: The Seven Leadership Leverage Points

Built to Last ; Jim Collins and Jerry Porras.

First, Break All the Rules: What the World’s Greatest Mangers Do Differently , Marcus Buckingham and Curt Coffman

The Leadership Challenge , James Kouzes and Barry Posner

The Carrot Principle Gostick and Elton 2007